UC-NRLF 


I 


173 


SURGICAL  NURSING  IN  WAR 


BUNDY 


SURGICAL  NURSING  IN  WAR 
B  U  N  D  Y 


BY  THE  SAME  AUTHOR 


Anatomy    and    Physiology    for 
Nurses        ::         ::        4th  Edition 

LETTERS 

"I  am  using  Bundy  and  find  it  unequalled  in  its 
purpose  for  a  concise,  readable  and  accurate  work  on 
the  human  body  .  .  .  it  is  indispensable." 

"As  proof  of  its  value  I  shall  introduce  it  here  into 
the  training  school  as  a  textbook." 

"I  find  that  it  exactly  fits  into  the  frame  for  which 
it  is  intended.  The  illustrations  could  hardly  be 
better  and  the  descriptive  matter  is  plain  and  con- 
cise. It  fully  answers  the  requirements  of  a  textbook 
for  nurses." 

"I  find  it  especially  adapted  for  a  nurse's  require- 
ments; it  is  terse  and  the  illustrations  are  excellent 
and  most  helpful." 

REVIEWS 

"Nearly  every  chapter  ends  with  a  paragraph  or 
two  headed  'Surgical  Notes'  or  'Clinical  Notes'  and 
this  of  course  adds  greatly  to  the  value." — Journal  of 
the  American  Medical  Association. 

"The  clinical  notes,  surgical  and  obstetrical,  inter- 
spersed throughout  the  text  are,  so  far  as  we  know, 
unique,  and  certainly  serve  to  fix  the  attention  and 
show  the  value  of  knowledge  which  might  otherwise 
appear  useless  and  barren." — N.  Y.  Medical  Journal. 

4th  Edition  revised,  enlarged.     With  a  Glossary. 

243  Illustrations,  46  in  colors.    Octavo  423  Pages. 

Cloth  $1.75  Postpaid. 


P.  BLAKISTON'S  SON  &  CO. 
PUBLISHERS         -        -         -         PHILADELPHIA 


SURGICAL  NURSING 
IN  WAR 


BY 
ELIZABETH  R.  BUNDY,  M.  D. 

MEMBER  OF  THE  MEDICAL  STAFF,  WOMAN'S  HOSPITAL,   PHILADELPHIA 
FORMERLY  ADJUNCT  PROFESSOR  OF,   AND  DEMONSTRATOR  OF, 
ANATOMY,    WOMEN'S     MEDICAL     COLLEGE,    PHILADEL- 
PHIA; FORMERLY   SUPERINTENDENT    OF    CON- 
NECTICUT   TRAINING    SCHOOL     FOR 
NURSES,   NEW  HAVEN,   ETC. 


AUTHOR   OF   A    TEXT   BOOK  OF  ANATOMY 
AND  PHYSIOLOGY  FOR  TRAINING  SCHOOLS 


WITH  37  ILLUSTRATIONS 


PHILADELPHIA 

P.   BLAKISTON'S  SON  &  CO. 

1012  WALNUT  STREET 


737 


COPYRIGHT,  1917,  BY  P.  BLAKISTON'S  SON  &  Co. 


'MA-PUB    F»R€33    YORK    PA. 


PREFACE 


The  surgical  literature  of  the  Great  War  already 
includes  many  scores  of  valuable  and  illuminating 
articles  contributed  to  various  periodicals,  and  a 
few  books.  From  these  voluminous  sources,  supple- 
mented by  letters  from  the  front,  it  has  been  thought 
desirable  to  collect  the  lessons  and  descriptions 
which  are  of  vital  import,  that  they  may  be  avail- 
able for  ready  reference  by  those  who  contemplate 
joining  the  nursing  corps  of  Military  Hospitals  (or 
have  already  done  so),  as  their  time  is  of  necessity 
too  limited  for  the  wide  reading  involved.  Useful 
suggestions  have  been  received  from  those  who  have 
been  personally  in  service  at  the  front,  and  indebted- 
ness is  hereby  acknowledged  to  the  valuable  work 
of  Major  Hull — "Surgery  in  War" — which  has  been 
freely  consulted  and  quoted  in  regard  to  descriptions 
of  methods  practised  by  members  of  the  Royal 
Army  Medical  Corps  of  Great  Britain. 

Any  attempt  at  completeness  in  a  book  of  this 
sort  would  be  futile,  as  new  methods  are  daily  devised 
and  daily  reported;  the  final  word  concerning  any 

V 

369895 


VI  PREFACE 

will  not  be  uttered  while  the  war  lasts;  but  the  prin- 
ciples upon  which  modern  war  surgery  is  based  are 
well  established,  and  upon  those  lines  is  built  the 
groundwork,  also,  of  surgical  nursing  in  war  time. 

ELIZABETH  R.  BUNDY. 

1831  CHESTNUT  STREET. 
October,  1917. 


CONTENTS 


CHAPTER  I 

PAGE 
Demands  upon  the  surgical  nurse  in  the  military  hospital; 

importance  of  preliminary  training I 

CHAPTER  II 

Missiles  used  in  modern  warfare;  effects;  bacteria;  their  preva- 
lence in  battle  grounds 8 

CHAPTER  III 

Effects  of  bacterial  invasion;  immunity;  how  jjecured.    ...     17 

CHAPTER  IV 
Dangers  of  infection;  shock;  hemorrhage 25 

CHAPTER  V 

Antiseptics;    hypochlorites;    saline   solutions;    dichloramin-T 

and  others 38 

CHAPTER  VI 

Condition  of  the  wounded  man;  effects  of  exposure  and  ex- 
haustion; general  care 63 

vii 


Vlii  CONTENTS 

CHAPTER  VII 

Mechanical  appliances;  splints;  plaster  of  Paris  dressings.   .     74 
CHAPTER  VIII 

Bath  treatment  in  surgical  nursing;  burns;  tetanus;  blood- 
vessel injuries;  gangrene 89 

CHAPTER  IX 

Bone  injuries;  compound  fractures;  injured  joints 106 

CHAPTER  X 

Injuries  of  the  head;  cranial  surgery;  after-care  of  patient; 
shell  shock,  etc 126 

CHAPTER  XI 

Injuries  of  the  cervical  region;  of  the  spine;  of  nerves;  effects 

and  symptoms 138 

CHAPTER  XII 

Injuries  of  the  chest  wall;  of  thoracic  organs;  operations  and 
nursing  care;  injuries  of  the  abdomen;  hemorrhage;  oper- 
ations and  after-care 150 

CHAPTER  XIII 
Other  conditions  incident  to  warfare 175 


SURGICAL  NURSING  IN  WAR 

CHAPTER  I 
SURGICAL  NURSING  IN  WARTIME 

In  the  present  wave  of  patriotism  many  nurses  will 
offer  themselves  for  service  at  or  near  the  front. 
That  they  may  understand  some  of  the  conditions 
which  there  exist  and  the  consequent  demands  upon 
them,  the  following  pages  are  written  to  set  forth 
not  only  the  problems  to  be  solved,  but  some  of  the 
means  which  have  thus  far  been  devised  to  that  end. 

It  is  assumed  that  one  who  volunteers  for  surgical 
work  in  the  war  hospital  has  already  mastered  the 
general  principles  of  nursing  and  by  practice  has 
acquired  the  requisite  experience  and  skill  to  make  her 
thoroughly  efficient.  While  it  is  true  that  the  great 
pressure  of  work  will  provide  something  of  impor- 
tance for  every  willing  hand,  the  responsible  nursing 
must  be  in  the  hands  of  responsible  nurses,  who  by 
their  thorough  understanding  of  the  situation  and 
duties,  can  not  only  render  valuable  service  them- 
selves, but  assume  the  very  important  duty  of 


2  WAR  NURSING 

directing  inexperienced  workers  when  only  such  are 
at  hand  to  assist  them,  for  in  the  large  base  hospitals 
where  from  2,000  to  2,500  patients  must  be  cared  for, 
it  is  impossible  to  obtain  a  sufficient  number  of 
graduate  nurses  for  the  purpose;  many  who  are 
untrained  are  necessarily  employed,  therefore  it  is 
all  the  more  important  that  the  graduate  nurse  should 
be  fully  prepared  to  master  the  situation. 

Although  in  the  following  pages  instruction  in 
general  nursing  is  omitted,  this  is  not  because  of  any 
lack  of  recognition  of  its  importance,  but  because  the 
design  of  the  book  is  to  aid  the  graduate  nurse  in 
preparation  for  the  present  emergency.  The  serious 
nature  of  her  duties  will  require  all  of  study  and  prepa- 
ration which  she  can  devote  to  the  undertaking. 

She  will  not  forget  her  early  training,  by  which  she 
has  become  expert  in  such  important  matters  as  bed 
making,  the  moving  and  lifting  of  patients,  the  giv- 
ing of  baths,  changing  of  clothing  and  bed  linen  with 
least  disturbance  to  the  patient,  and  the  ability  to 
secure  by  various  devices — so  far  as  possible,  his 
comfort.  Of  utmost  importance  is  the  correct  ad- 
ministration of  demches,  rectal  irrigations  and  ene- 
mata,  colon  la/age,  the  preparation  and  use  of  hot 
and  cold  apoHcations,  and  many  other  local  remedies 
for  variou^purposes.  She  will,  of  course,  have  been 
well  drilled  in  bandaging  and  the  preparation  and 
use  of  splints;  She  will  understand  the  importance 


SURGICAL  NURSING  IN  WARTIME  3 

of  the  use  of  antiseptics  and  the  handling  of  aseptic 
wounds.  She  will  know  so  exactly  how  to  prepare 
patients  for  operation  that  she  will  do  this  quickly 
and  well;  she  will  know  for  what  symptoms  to  watch 
after  an  operation  and  will  have  these  points  so  clear 
in  her  own  mind  that  she  can  instruct  her  assistants 
concerning  them  and  depend  upon  their  reports  with 
confidence.  The  care  of  surgical  dressings  and  appli- 
ances may  fall  to  her  hands,  as  well  as  the  preparation 
of  surgical  supplies.  All  these  things  must  be  liter- 
ally "at  her  fingers'  ends." 

The  structure  of  the  human  body  and  the  relations  of 
its  parts  must  be  well  understood  and  constantly  in 
mind,  for  only  so  may  she  be  able  to  comprehend  the 
derangements  caused  by  accident  or  disease,  or 
attain  the  skill  which  intelligence  in  nursing  confers. 

Therefore,  her  studies  in  Anatomy  and  Physiology 
may  be  profitably  reviewed;  this  is  especially  im- 
portant for  surgical  work  and  as  most  of  her  activities 
will  be  in  that  field,  a  number  of  illustrations  (with 
which  she  is  perhaps  already  familiar)  are  introduced 
with  explanations  adapting  them  to  the  cases  which 
are  most  frequently  entrusted  to  her  care. 

It  is  unnecessary  to  speak  of  the  requisite  personal 
qualifications  of  the  nurse;  such  as  patience,  kind- 
ness of  heart  and  manner,  a  power  of  unremitting 
attention  and  that  indescribable  quality  called  tact. 
But  it  is  of  first  importance  to  call  attention  to  the 


fact  that  she  can  not  meet  the  exacting  duties  which 
confront  her  without  proper  conservation  of  her  own 
health  and  strength.  She  must  religiously  make  use 
of  her  stated  opportunities  for  rest  and  fresh  air 
whenever  possible,  not  only  for  her  own  sake,  but  for 
that  of  the  cause  to  which  she  has  pledged  herself. 

Her  responsibilities  will  be  great,  beyond  that  of 
any  work  which  she  has  ever  before  undertaken,  not 
alone  because  of  the  kind  of  work  itself,  but  because 
the  demand  is  so  continuous;  each  hour  of  day  or 
night  may  bring  its  own  emergency. 

She  should  understand  much  from  the  surgeon's 
point  of  view  in  order  to  be  his  very  efficient  aid, 
and  much  also  from  the  patient's  point  of  view  that 
she  may  the  better  minister  to  his  needs.  Here  more 
constantly  than  elsewhere,  alert  attention,  quick 
thinking  and  unhesitating  action  are  demanded,  and 
the  unflagging  interest  which  makes  for  endurance. 
The  work  is  most  arduous;  the  reward  is  of  the 
highest. 

A    FEW    GENERAL    REMINDERS    APPLICABLE    ALL 
ALONG  THE  LINE 

i.  Against  drawing  bed  covers  down  tightly  so 
that  they  become  binders.  Nothing  can  be  more 
disagreeable,  especially  for  patients  who  must  lie 
upon  the  back,  than  to  have  the  toes  bound  down  by 
covers. 


SURGICAL  NURSING  IN  WARTIME  5 

2.  Contrive  to  have  at  hand  pads  or  pillows  of 
many  sizes.     Upon  their  use  and  arrangement  so 
much  depends  that  their  importance  can  hardly  be 
overestimated.     It  is  here  that  the  nurse's  knowledge 
of  anatomy  will  serve  her  well,  so  that  she  will  know 
just  where  to  place  them  in  seeking,  for  example, 
to  exactly  support  the  normal  curves  of   body  or 
limb.     She  will  know  the  position  of  the  patient's 
head  which  will  bring  no  strain  upon  the  muscles  of 
the  neck;  the  patient  himself  will  not  as  a  rule  under- 
stand  why   his   head   is   not   always   comfortable, 
therefore  the  wise  and  observant  nurse  must  herself 
recognize  the  state  of  affairs,  and  find  her  reward  in 
the  look  of  relief  and  contentment  upon  her  patient's 
face  when  a  deft  although  slight  re-arrangement  has 
added  to  his  comfort. 

3.  A  thin  bed  transmits  the  body  heat  of  the  occu- 
pant to  the  iron  frame  which  supports  it;  a  non- 
conducting material  placed  underneath  the  mattress 
will  prevent  this.     Nothing  is  better  for  the  purpose 
than  several  layers  of  paper;  news  papers  serve  per- 
fectly well,  secured  if  possible  to  a  layer  of  any  sort 
of  clean  material;  when  that  is  not  obtainable  they 
may    be    overlapped    and   tacked  firmly  together. 
This  device  will  contribute  surprisingly  to  the  com- 
fort of  a  patient  in  cold  weather,  and  such  a  provision 
for  a  case  of  shock  is  most  valuable. 

4.  Do  not  attempt  to  give  a  high  enema  with- 


0  WAR  NURSING 

out  elevating  and  supporting  the  hips.  If  the  case 
admits  vary  the  patient's  position  during  the  ad- 
ministration, from  the  back  to  the  left  side  and  then 
to  the  right,  that  the  water  may  follow  the  curves  of 
the  large  bowel. 

5.  Concerning  the  wisdom  of  providing  for 
personal  use: 

First. — As  many  rubber  gloves  as  she  can  possibly 
procure,  securely  packed  for  transit;  (the  handling 
of  dangerous  infections  will  be  so  much  more  easily 
and  therefore  better  done  if  one  can  work  with  the 
mind  free  from  the  thought  of  personal  danger). 

Second. — Several  pairs  of  dressing  forceps  or 
hemostats,  to  prevent  any  necessity  for  touching 
dressings. 

Third. — As  many  hypodermic  needles  as  possible. 
You  can  not  have  too  many.  Also  tablets — morphia, 
adrenalin,  pituitary  extract,  scopolamin — will  be 
needed  most  frequently."  Supposedly  these  are 
furnished  for  use  from  the  hospital  stores,  but  it  is 
hardly  possible  to  have  a  sufficient  number  always 
on  the  spot,  and  the  devoted  nurse  will  be  more  than 
compensated  for  personal  outlay  by  the  sustaining 
knowledge  that  she  is  ready  for  the  emergencies 
which  will  arise  when  supplies  may  be  temporarily 
inadequate  to  a  sudden  demand  and_a  life  at  stake 
may  be  saved  by  her  hand. 

In  the  succeeding  pages  no  attempt  will  be  made 


SURGICAL  NURSING  IN  WARTIME  7 

to  emphasize  the  terrible  and  distressing  features  of 
the  work  in  Army  hospitals,  nor  to  call  attention 
especially  to  the  pressure  under  which  it  is  carried 
on  during  much  of  the  time,  but  in  some  situations, 
as  for  instance  where  800  men  are  hurried  in,  scores 
at  a  time,  all  suffering  for  immediate  attention — 
some  fast  slipping  away  from  the  reach  of  human 
aid — the  nurse  will  wish  that  each  of  her  hands  could 
be  multiplied  to  a  hundred  in  order  to  accomplish 
all  that  she  sees  before  her — crying  to  be  done! 

It  is  appalling !  but  there  will  be  no  time  for  dwell- 
ing on  that,  still  less  for  being  appalled.  She  will 
just  go  ahead — thinking  fast,  fast — and  trying  to 
persuade  her  willing  hands  and  those  of  her  assistants 
to  keep  the  pace. 


CHAPTER  II 

MISSILES  USED  IN  MODERN  WARFARE  AND 
THEIR  IMMEDIATE  EFFECTS 

Lieutenant-Colonel  Pilcher,  of  the  Royal  Army 
Medical  Corps,  says  of  gunfire:  "this  war  will  be 
known  to  the  minds  of  surgeons  as  the  pointed 
bullet  war."  The  special  effect  of  these  bullets  is 
to  cause  deep  penetration,  with  extensive  shattering 
of  bone  and  injury  to  the  soft  tissues. 

Artillery  fire  also,  so  very  large  an  element  in  the 
European  war,  deals  in  the  use  of  explosive  missiles, 
as  shrapnel, 'high  explosive  shells,  etc.,  the  fragments 
of  which  pierce  the  soldier's  body  in  every  possible 
place.  No  part  escapes  and  every  sort  of  wound  is 
caused,  from  a  simple  puncture  or  superficial  lacera- 
tion to  those  where  tissues  are  mangled,  bones  shat- 
tered and  nerves  cut  off  from  their  terminations. 
The  effect  of  this  mutilation  of  the  tissues  by  explo- 
sive missiles  with  the  shattering  of  bone  and  scattering 
of  fragments,  is  to  cause  wounds  within  wounds,  deep 
recesses  and  pockets  difficult  of  access  by  the  surgeon, 
where  anaerobic  bacilli  like  nothing  better  than  to 
hide  undisturbed;  hence  their  especially  dangerous 
character.  These  bacilli  flourish  on  dead  or  devital- 
ized tissue;  the  latter  are  already  in  the  wound;  the 

8 


MISSILES  USED  IN  MODERN  WARFARE  9 

former  soon  will  be.  They  crave  a  place  devoid  of 
oxygen — they  find  such  in  the  recesses  of  a  wound 
plugged  with  debris  and  damaged  tissues  so  that  air 
can  not  enter.  They  object  to  an  acid  medium — 
the  blood  is  alkaline.  They  work  in  the  dark;  no 
light  is  here.  In  and  around  the  wound  their  dan- 
gerous toxins  are  developed  at  once,  and  being  rapidly 
absorbed  they  cause  the  most  serious  consequences. 
In  addition  to  the  various  results  of  gunfire, 
the  use  of  bombs  or  hand  grenades,  "liquid  fire," 
asphyxiating  gases  and  burning  oil,  in  the  European 
war,  has  added  to  the  list  of  bodily  wounds.  Ex- 
tensive burns  involving  deep  layers  of  skin  and 
underlying  tissues  exposed  to  the  infections  of  the 
battlefield  without  means  of  defense,  have  presented 
problems  of  treatment  to  both  surgeon  and  nurse,  as 
will  be  recognized;  being  superficial  wounds  they  are 
mostly  infected  by  the  pus-forming  microbes  (aerobes) 
which  can  be  adequately  met  and  conquered  by 
prompt  treatment  if  only  the  strength  of  the  patient 
be  not  too  severely  taxed. 

The  shock  and  exhaustion  following  extensive  burns  will 
be  referred  to  later  with  descriptions  of  treatment  (pp.  27, 90). 

The  immediate  effects  of  asphyxiating  gases  en- 
countered in  volume,  are  difficult  to  relieve.  The 
main  hope  for  the  soldier  is  in  prophylaxis;  by  the 
use  of  a  gas  mask  or  respirator  he  will  escape  the 


10  WAR  NURSING 

effects  of  the  noxious  fumes  which  have  such  a  deadly 
effect.  Once  inhaled  they  cause  intense  suffering 
from  the  inability  of  the  badly  damaged  lung  tissue 
to  properly  carry  on  the  process  of  respiration,  the 
man  literally  gasping  for  breath,  at  the  same  time 
enduring  agonizing  pain.  If  he  survive  the  imme- 
diate effects  of  the  attack  he  must  undergo  a  long 
period  of  disability  due  to  the  congestion  and  suc- 
ceeding inflammation  of  the  air  passages  and 
lung  tissue. 

As  time  goes  on,  remedies  are  sought  and  found  for 
many  conditions  which  at  first  seemed  beyond  alle- 
viation, and  improved  methods  of  treatment  may 
yet  help  the  soldier  through  this  as  well  as  other 
well-nigh  impossible  difficulties. 

Long  and  persistent  attempts  to  revive  by  arti- 
ficial respiration  one  who  appears  quite  asphyxiated 
by  gas,  have  sometimes  saved  the  patient. 

Injuries  caused  by  hand  grenades  or  bombs,  burn- 
ing oil  and  numerous  other  vicious  weapons  invented 
in  the  present  war,  can  not  be  described  in  detail 
but  may  be  classed  under  a  general  heading  as 
wounds  of  mutilation,  and  burns. 

The  clean  bullet  wound  at  long  range  is  often  un- 
contaminated.  Buried  in  the  tissues  it  has  been 
found  sterile  when  extracted,  but  in  the  present  war 
this  does  not  often  happen.  Even  when  there  is 
no  infection,  pressure  symptoms  may  cause  it  to  be 


MISSILES  USED  IN  MODERN  WARFARE  II 

a  source  of  danger,  as  in  the  spinal  column  or  the 
vicinity  of  blood-vessels. 

The  bayonet  wound,  received  with  the  force  of 
the  thrust  undiminished,  goes  home  usually  to  vital 
organs  or  causes  internal  hemorrhage,  and  the  man 
will  not  live  to  reach  the  nurse's  hands. 

The  term  "spreading  wound11  is  often  used.  This 
expresses  the  effect  of  a  missile  coming  rapidly  from 
a  distance,  and  possessing  sufficient  force  to  penetrate 
the  body  but  with  diminishing  velocity.  It  thus 
produces  the  effect  of  a  blow  resisted  after  entering 
the  body,  causing  an  injury  which  spreads  laterally 
in  the  tissues  which  it  meets.  A  bullet,  being  com- 
paratively small  and  compact,  usually  makes  a  clean 
straight  punctured  wound;  if  it  takes  a  "  through-and- 
through"  course  the  exit  opening  is  larger  than  that 
of  entrance ;  some  velocity  having  been  lost  in  transit, 
a  slight  spreading  occurs. 

Shrapnel  or  shell  fragments  cause  far  more  spreading 
and  the  damage  is  correspondingly  greater.  Their 
shape  and  rough  edges  enhance  their  destructive 
character,  while  their  "spreading"  or  scattering  course 
multiplies  wounds  in  all  of  the  structures  in  their 
path. 

CONDITIONS  OF  WARFARE.    BACTERIOLOGY 

The  most  striking  difference  between  surgical 
work  in  civil  life  and  in  the  present  war,  appears  in 


12  WAR  NURSING 

the  fact  that  the  former  deals  with  clean  wounds, 
only  at  times  with  infected  ones — while  the  latter 
deals  with  infected  wounds,  almost  never  with  clean 
ones.  The  surgical  cases  with  which  we  have  hereto- 
fore been  familiar  in  hospitals  or  at  patients'  homes, 
often  present  themselves  with  evidences  of  infection, 
but  with  a  few  exceptions  this  may  be  arrested  by 
skilful  treatment,  as  the  wounds  are  accessible 
whether  accidental  or  operative,  pus-forming  sur- 
faces are  under  control,  care  and  surroundings  are 
of  the  best  and  serious  consequences  are  averted. 

War  surgery,  on  the  contrary,  has  to  deal  with 
wounds  of  a  different  character,  in  surroundings 
often  most  unfavorable  and  where  a  minimum  of 
care  is  available  for  the  patient.  The  character 
of  warfare  influences  greatly  the  nature  and  severity 
of  wounds.  Life  in  the  trenches  with  its  confine- 
ment in  unwholesome  quarters  and  state  of  constant 
apprehension,  and  trench  warfare  itself  where  men 
are  exposed  to  the  effects  of  deadly  explosives  in  a 
narrow  space,  produce  their  own  consequences 
which  follow  no  other  conditions. 

Modern  destructive  missiles  cause  wounds  of  pe- 
culiar severity  and  render  more  active  all  of  the  infect- 
ive processes  to  which  the  man  is  exposed.  These 
circumstances  have  led  to  a  searching  study  of  infect- 
ive organisms  and  the  means  of  dealing  with  them, 
whereby  the  results  of  treatment  have  become  bril- 


BACTERIA  1.3 

liant,  notwithstanding  the  unfavorable  conditions 
which  are  met  on  every  side. 

It  has  been  said  truly  that  the  bacteriology  of 
infected  wounds  in  time  of  war  is  that  of  the  battle- 
ground. By  way  of  contrast,  the  experience  of 
military  surgeons  in  South  Africa  is  often  referred  to, 
where  much  of  the  fighting  was  done  over  unculti- 
vated plains  in  uncontaminated  air;  sepsis  was  not  the 
rule  and  when  present  it  yielded  readily  to  treatment. 
The  present  war,  on  the  contrary,  is  waged  in  coun- 
tries long  inhabited  by  a  dense  population,  where 
for  many  generations  the  land  has  been  under  inten- 
sive cultivation  with  the  use  of  fertilizers  of  animal 
origin  which  are  an  abounding  source  of  dangerous 
bacteria. 

The  soil  is  full  of  them  and  infection  is  invited  by 
the  methods  of  modern  warfare,  where  the  men  live 
in  trenches  for  weeks  at  a  time,  and  are  constantly 
showered  with  earth  thrown  up  by  explosions  on  all 
sides. 

BACTERIA 

Some  knowledge  of  the  special  bacteriology  of 
wounds  is  important  to  the  nurse  as  well  as  to  the 
surgeon  and  a  very  brief  statement  of  the  prominent 
features  of  the  subject  follows. 

The  bacteria  with  which  we  are  principally  con- 


14  WAR  NURSING 

earned  belong  to  two  general  classes:  the  aerobes  and 
the  anaerobes. 

Aerobes  require  the  presence  of  oxygen  for  their 
development;  common  examples  are  the  staphylo- 
coccus,  the  streptococcus,  the  colon  bacillus  and  the 
bacillus  pyocyaneus.  One  or  more  of  these  will  be 
found  wherever  suppuration  exists.  They  are  the 
pyogenic  or  pus-producing  bacteria.  The  most 
virulent  of  the  aerobes  is  the  streptococcus  pyogenes, 
which  is  the  cause  of  septicemia  or  general  sepsis,  and 
pyemia  or  abscess  development  in  different  organs 
(a  secondary  process). 

The  action  of  aerobic  bacteria  is  familiar  to  all 
who  have  done  much  surgical  work.  When  present 
extensively  they  have  a  devitalizing  effect  upon  the 
tissues  surrounding  the  wound,  as  is  seen  in  the  pro- 
duction of  sloughs.  Serious  as  these  may  be  they 
are  usually  dealt  with  successfully  by  antiseptic 
methods. 

Anaerobes  can  not  grow  in  the  presence  of  free 
oxygen ;  examples  are — the  bacillus  of  malignant  edema , 
bacillus  of  tetanus  and  the  so-called  gas  bacillus  (or 
the  bacillus  perfringens). 

Facultative  aerobes  or  anaerobes  form  a  class  which  may  or 
may  not  grow  in  the  presence  of  oxygen. 

Anaerobes  include  those  bacteria  which  cause  the 
most  serious  and  fatal  infections.  They  develop 
their  toxins  where  oxygen  is  not;  they  flourish  in  dead 


EFFECTS   OF  BACTERIA  15 

or  devitalized  tissue,  and  must  live  in  an  alkaline 
(or  at  least  a  neutral)  medium;  also,  they  produce 
spores  which  are  more  or  less  resistant  to  heat  or  anti- 
septics, and  remaining  inactive  for  an  indefinite  time, 
may  later  develop. 

NOTE. — Thorough  and  long  sterilization,  of  all 
articles  used  in  cases  of  anaerobic  infection,  as  in- 
struments, gloves,  utensils,  etc.,  is  imperative.  This 
is  best  accomplished  by  steam  under  pressure  in 
the  autoclave. 

All  bacteria  cause  their  effects,  not  by  their  mere 
presence,  but  by  the  toxins  or  poisons  which  they 
produce.  •  These  toxins  are  distributed  in  the  body 
and  destroy  the  cells  of  various  vital  tissues.  The 
aerobic  bacteria  flourish  in  all  tissues  where  air  can  be 
provided  and  produce  their  toxins  wherever  they  may 
be,  in  various  parts  of  the  body,  being  transported  in 
the  blood  current;  the  anaerobic  bacteria  produce  their 
toxins  in  the  wounds  where  they  find  entrance  and 
in  the  tissues  that  immediately  surround  the  wounds, 
whence  they  (the  toxins)  are  distributed  through 
the  body  by  way  of  the  blood  and  lymph  streams. 

Immediate  Effects  of  Certain  Anaerobic  Bacteria. 
-The  bacillus  of  malignant  edema  causes  a  rapid 
exudation  of  blood-stained  serum  in  the  subcutaneous 
tissues  and  muscles.  This  so  presses  upon  vessels 
as  to  obstruct  the  circulation  and  leave  the  parts  un- 
protected against  the  attack  of  the  bacilli,  so  that 


t6  WAR  NURSING 

death  of  the  tissue  and  gangrene  (not  often  with  gas) 
soon  follow.  The  toxin  produced  by  this  bacillus, 
when  absorbed  is  quickly  fatal. 

The  so-called  gas  bacillus  (bacillus  perfringens  or 
bacillus  aerogenes  capsulatus)  also  causes  an  exuda- 
tion of  serum  and  in  addition,  the  formation  of  gas, 
producing  an  emphysema  which  spreads  rapidly, 
forcing  itself  through  subcutaneous  tissues  and  be- 
tween muscles.  This  condition  created  by  gas  and 
serum,  obstructs  the  circulation  and  damages  the 
tissues.  The  effects  are  shown  in  pressure  symptoms 
which  so  often  are  followed  by  atrophy  of  muscles 
and  fatal  gangrene,  due  to  the  obstruction  of  vessels 
and  nerves  (see  p.  103). 

NOTE. — General  toxemia  of  the  patient  is  not 
caused  by  this  bacillus  itself.  When  present  it  is 
due  to  other  infective  organisms  or  a  "  mixed 
infection." 

The  toxin  of  the  tetanus  bacillus  attacks  the 
nerves  in  the  wound  where  it  is  produced  and  is 
carried  to  the  nerve  cells  of  the  central  nervous  sys- 
tem, affecting  first  those  which  belong  to  the  injured 
motor  nerves;  later,  it  invades  very  widely  the  cells 
of  the  brain  including  pons  and  medulla,  where  are 
found  the  vital  parts  of  the  nervous  system.  All 
these  organisms  produce  a  toxin  which  acts  on  the 
heart;  in  fatal  cases  the  pulse  fails  while  the  mind  is 
still  clear. 


CHAPTER  III 

EFFECTS  OF  BACTERIAL  INVASION  AND 
IMMUNITY 

Reviewing  your  studies  of  the  blood  you  will  recall 
that  it  consists  of  fluid  plasma  with  the  red  and  white 
cells  floating  therein;  also  various  substances  in 
solution,  among  which  is  one  called  complement; 
this  is  an  enemy  to  poisonous  bacteria. 

Certain  of  the  white  cells  or  leucocytes  are  called 
phagocytes  from  their  property  of  absorbing  and  de- 
stroying (or  devouring)  bacteria.  But  the  phago- 
cytes are  not  attracted  by  living  bacteria — on  the 
contrary,  they  are  repelled  by  them;  therefore,  the 
bacteria  must  die. 

What  happens  in  the  blood  when  injurious  bac- 
teria gain  entrance?  At  once  they  develop  their 
toxins  and  pour  them  into  the  stream.  Thus  they 
poison  the  blood  and  when  they  are  present  in  over- 
powering numbers  they  attack  the  tissue  cells  and 
general  poisoning  follows,  constituting  the  fully  de- 
veloped disease  which  is  attributable  to  the  special 
order  of  bacteria  present.  If  this  process  is  not 
arrested  death  follows. 

2  17 


1 8  WAR  NURSING 

IMMUNITY 

Nature  has  her  own  method  of  resisting  and  over- 
coming the  effects  of  bacterial  invasion,  thereby 
creating  a  condition  of  safety  which  is  called  im- 
munity or  insusceptibility. 

The  presence  of  bacteria  with  their  toxins  stimu- 
lates the  production  of  antitoxins  in  certain  tissue 
cells  of  the  body.  If  only  a  few  organisms  gain  en- 
trance the  quantity  of  antitoxin  will  be  sufficient  to 
neutralize  all  of  the  toxin  produced.  Meanwhile, 
the  tissue  cells  under  this  stimulation  produce  other 
substances  classed  as  amboceptor,  which  uniting  with 
the  complement  always  present  in  the  blood  attaches 
it  to  the  bacteria;  they  are  then  promptly  killed 
and  further  production  of  toxin  is  prevented.  They 
are  now  ready  for  the  phagocytes,  which  destroy  them. 

NOTES. — Complement  alone  is  powerless:  armed 
with  amboceptor  it  is  deadly.  Toxin  stimulates  the 
production  of  antitoxin  which  keeps  the  poisonous 
process  in  check  until  sufficient  amboceptor  is  pro- 
duced to  attach  the  deadly  complement  to  the 
bacteria. 

When  all  of  the  bacteria  are  killed  the  patient 
recovers. 

By  a  fortunate  provision  of  Nature  an  excess  of 
amboceptor  always  remains  in  the  blood,  ready  for  a 
future  invasion  of  the  same  organism.  This  consti- 
tutes immunity  to  that  special  organism. 


BACTERIAL  INVASION  AND  IMMUNITY  1 9 

NOTES. — Phagocytes  do  not  devour  living  bac- 
teria, but  the  production  of  antitoxin  occurs  in  their 
presence  whether  living  or  dead. 

Amboceptor  includes  a  variety  of  substances,  as 
agglutinins,  opsonins,  antibodies,  immune  bodies,  etc., 
all  acting  in  the  same  way,  to  unite  with  comple- 
ment and  enable  it  to  kill  the  bacteria  so  that  the 
phagocytes  will  be  attracted  to  the  feast. 

Immunity,  then,  consists  of  the  presence  in  the 
blood  of  sufficient  immune  bodies  or  amboceptor  to 
attach  the  deadly  complement  to  the  variety  of  in- 
vading bacteria  which  first  stimulated  its  production. 

Each  immune  body  can  act  upon  only  one  species 
of  bacteria — the  one  which  stimulates  its  own  pro- 
duction. Immunity,  therefore,  is  not  a  condition 
in  general,  but  must  be  especially  acquired  for  each 
separate  infection. 

Acquired  immunity  to  any  disease  is  enjoyed  by 
the  person  who  has  successfully  passed  through  an 
attack  of  that  disease;  the  excess  of  immune  bodies 
or  amboceptor  remaining,  being  able  to  guard  him 
against  a  succeeding  invasion  of  the  organism  which 
caused  its  production. 

This  form  of  immunity  is  not  invariably 
permanent. 

Natural  immunity  is  hardly  explainable;  some 
races  and  some  individuals  simply  do  not  "take" 
certain  diseases. 


26  WAR  NURSING 

Artificial  immunity  is  acquired  at  will,  by  the  in- 
troduction into  the  blood  of  bacteria  living  or  dead, 
which  stimulate  the  production  of  antitoxin  and  the 
appropriate  amboceptor.  The  amboceptor  remains 
and  the  person  is  immune  or  insusceptible  to  the 
bacteria  in  question  for  a  variable  time.  This  is  the 
secret  of  successful  vaccination  as  practised  so  long 
and  successfully  to  protect  an  individual  from  small- 
pox. (The  vaccine  is  skilfully  prepared  and  the  num- 
ber of  bacteria  actually  determined  in  the  laboratory.) 

NOTE. — In  the  case  of  antityphoid  vaccination 
immunity  continues  for  about  two  years.  Where 
the  danger  of  exposure  is  constant  and  can  not  be 
avoided  it  is  best  to  repeat  the  vaccination  at  shorter 
intervals.  In  the  present  war  the  antityphoid  vac- 
cine is  administered  to  every  recruit  when  he  is 
enlisted  and  repeated  at  each  subsequent  enlistment. 
When  he  is  in  a  locality  known  to  be  infected  it  is 
repeated  at  intervals  of  two  or  more  months  during 
the  time  of  exposure.  (This  system  of  frequent 
vaccination  obtains  in  certain  localities  where  the 
men  have  to  encounter  disease  of  an  especially 
severe  type.) 

Summary. 

1.  Complement  exists  normally  in  the  blood. 

2.  The    production    of    antitoxin    occurs    in    the 
presence  of  either  living  or  dead  bacteria;  also  the 
production  of  amboceptor. 


BACTERIAL  INVASION  AND  IMMUNITY  21 

3.  While   the   antitoxin    is   neutralizing  the  tox- 
ins which  are  poured  into  the  blood  by  living  bac- 
teria,   the   amboceptor   is   liberated   and  joins  the 
complement. 

4.  When  this  is  accomplished  bacteria  are  killed 
and  phagocytes  devour  them. 

5.  Immunity  is  conferred  by  excess  of  amboceptor 
remaining  in  the  blood. 

NOTES. — Phagocytes  are  attracted  by  dead  bac- 
teria. This  attraction  is  explained  as  positive  chemio- 
taxis.  They  are  repelled  by  living  bacteria;  this 
is  explained  as  negative  chemiotaxis. 

The  word  antigen  is  applied  to  any  organized  sub- 
stance of  animal  origin  which  stimulates  these  proc- 
esses of  self  defense.  In  the  preceding  studies 
bacteria  are  the  antigens. 

Serum  Treatment  and  Vaccination. — The  use  of 
antitoxin  serum  is  illustrated  in  the  treatment  of 
diphtheria  and  tetanus.  It  is  obtained  by  means  of 
a  series  of  injections  of  bacteria  into  the  body  of  the 
horse,  whereby  excessive  quantities  of  antitoxin  are 
produced  in  the  blood.  This  is  drawn  from  the  veins 
and  the  serum  with  its  load  of  antitoxin  is  separated 
from  the  blood.  Its  strength  is  then  estimated  and 
expressed  in  units.  It  is  sealed  in  sterile  bottles  in 
measured  amounts  marked  for  administration.  For 
a  person  who  has  been  exposed  to  infection  a  certain 


22  WAR  NURSING 

quantity  called  the  immunizing  dose  is  injected  into 
the  tissues.  For  a  patient  already  suffering  from 
the  disease  a  larger  quantity  is  used;  this  is  the 
remedial  or  therapeutic  dose. 

In  vaccination  dead  bacteria  are  introduced  in  an 
emulsion  and  the  natural  powers  are  stimulated 
safely  to  produce  the  necessary  amount  of  antitoxin 
and  immune  body,  or  amboceptor.  The  effect  is 
illustrated  in  the  use  of  antityphoid  or  antienteric 
vaccine. 

NOTES. — In  the  use  of  serum  the  antitoxin  is  sup- 
plied from  without,  with  the  confident  expectation 
that  by  neutralizing  the  toxin  that  may  be  present  in 
the  blood  it  will  give  the  cells  time  to  produce  the 
necessary  amboceptor. 

In  the  use  of  vaccine  the  body  must  rise  to  the  oc- 
casion, producing  its  own  antitoxins  and  sufficient 
amboceptor  to  meet  a  possible  future  invasion  of 
living  bacilli. 

No  one  has  ever  seen  complement  or  amboceptor, 
but  the  result  of  their  action  has  been  proven  many 
times  and  the  terms  signify  theoretically,  a  process 
which  undoubtedly  takes  place  in  the  blood. 

The  usual  preparations  before  and  after  a  punc- 
ture of  the  skin  are  to  be  made  for  the  adminis- 
tration of  serum  or  vaccine ;  the  skin  to  be  thoroughly 
cleansed  and  disinfected.  Iodine  may  be  used  or  not 


BACTERIAL  INVASION  AND  IMMUNITY  23 

as  directed  at  the  time.  (Iodine  should  be  omitted 
for  a  vaccination.)  Sterile  water  or  normal  saline  is 
to  be  used  for  the  final  washing  or  dressing  after  the 
cleansing  and  disinfecting. 

Constitutional  Symptoms  or  Reactions  Produced 
by  Serum  ("serum  sickness."). — The  site  of  the 
injection  may  become  slightly  swollen  and  tender. 

Rise  of  temperature  occurs  in  from  24  to  48  hours, 
with,  frequently,  nausea  and  restlessness  and  often  a 
fine  rash,  "serum  rash.1'  There  is  slight  disturb- 
ance of  the  bowels.  The  symptoms  often  persist 
for  several  days  or  a  week,  although  they  may  sub- 
side within  48  hours.  The  nursing  is  of  the  sim- 
plest; the  patient  should  rest  quietly,  the  diet  should 
be  light  and  digestible.  Cool  drinks  may  be  given 
freely  and  very  little  medicine  is  required. 

Symptoms  Produced  by  (Antityphoid  or  Antien- 
teric)  Vaccine. — These  are  headache,  feverishness, 
a  feeling  of  general  malaise  and  possibly  faintness, 
which  sometimes  makes  the  patient  quite  uncom- 
fortable. They  occur  within  a  few  hours  (about  six) 
from  the  reception  of  the  vaccine.  If  the  dose  is 
administered  rather  late  in  the  day  the  symptoms  will 
not  occur  until  bedtime  and  the  patient  will  sleep 
through  the  most  annoying  stage  of  the  reaction. 
The  swelling  and  tenderness  which  surround  the 
puncture  begin  to  subside  at  the  end  of  24  hours. 


24  WAR  NURSING 

Two  days'  relief  from  duty  will  probably  find  him  in 
his  normal  condition. 

In  exceptional  cases  the  symptoms  are  more  seri- 
ous— vomiting,  diarrhea,  fainting,  fever;  they  will 
probably  subside  in  two  or  more  days. 


CHAPTER  IV 

DANGERS  OF  INFECTION.     SHOCK. 
HEMORRHAGE 

Already,  attention  has  been  called  to  the  character 
of  warfare  and  the  location  of  the  battle  grounds  as 
elements  which  add  greatly  to  the  serious  nature  of 
infective  processes.  Not  only  are  the  wounds  caused 
by  modern  missiles  peculiarly  dangerous  owing  to 
the  wholesale  destruction  of  tissues  involved,  but  on 
account  of  the  substances  which  are  driven  into 
them — skin — clothing  and  dirt — all  with  their  freight 
of  microbes  more  or  less  virulent. 

The  man  himself  presents  a  state  which  favors  the 
rapid  development  of  toxins  and  general  sepsis. 
Exposure  for  hours  or  days  as  circumstances  deter- 
mine, during  which  the  only  protection  for  his  wounds 
was  possibly,  a  first  aid  dressing  applied  by  himself 
amid  unclean  conditions,  has  sapped  his  vitality  and 
undermined  his  power  of  resistance,  thus  providing 
opportunity  for  microbes  to  do  their  worst. 

The  aerobes  or  pus-producing  bacteria  (staphylo- 
cocci  and  streptococci)  are  present  in  large  numbers 
engaged  in  breaking  down  his  tissues,  while  in  deeply 
lacerated  wounds  the  anaerobes  find  conditions  to 


26  WAR  NURSING 

their  liking;  they  do  not  of  themselves  cause  septi- 
cemia,  the  suppuration  which  often  accompanies 
them  being  due  to  other  organisms,  in  the  presence 
of  which  the  anaerobes  themselves  flourish  the  more 
abundantly  in  dead  tissues  thus  provided  for  them. 

When  the  wounded  man  reaches  the  nurse  after 
exposure  long  or  short,  he  has  been  subjected  to  the 
nerve  strain  of  constant  distress  and  apprehension 
and  the  terrifying  experience  of  gunfire  with  explo- 
sives, bombing,  etc.,  in  addition  to  the  physical  ex- 
haustion of  actual  fighting  and  the  pain  of  wounds. 
Add  to  these  contamination  by  soil,  sepsis  already 
developed,  and  the  sufferings  of  transportation — 
first  through  narrow  trenches  by  stretcher,  then  over 
rough  ground  by  ambulance  and  later  by  not  too 
comfortable  railway  train.  He  may  be  weakened 
by  hemorrhage;  he  is  suffering  protracted  pain;  all 
these  will  react  to  reduce  him  to  a  condition  of  shock. 

SHOCK 

This  may  be  the  first  problem  which  the  nurse 
is  called  upon  to  meet.  If  she  is  fortunate 
enough  to  be  stationed  at  a  clearing  hospital1  (next 
removed  to  the  field  hospital  or  ambulance),  she 
will  meet  such  cases  constantly,  for  the  men  are 
necessarily  transported  while  hardly  able  to  endure 
the  hardships  of  the  trip.  At  a  base  hospital  the 

1  Evacuation  hospital. 


DANGERS  OF  INFECTION.      HEMORRHAGE          27 

condition  of  the  patient  may  be  still  more  desperate, 
and  the  operations  demanded  for  his  relief  will  fur- 
nish many  a  serious  case. 

The  appearance  of  a  patient  in  shock  is  that  of 
complete  exhaustion,  with  vitality  almost  suspended. 
The  skin  is  cold,  clammy  and  pale,  the  features  are 
pinched — the  pupils  wide  open,  the  muscles  relaxed. 
Respirations  are  slow,  shallow  and  irregular;  circula- 
tion is  at  the  lowest  ebb;  the  pulse  is  small,  rapid  and 
feeble,  the  temperature  subnormal.  All  functions 
are  depressed. 

Accepting  the  teaching  of  Dr.  George  W.  Crile  we 
now  believe  that  shock  is  a  condition  of  brain  exhaus- 
tion and  abnormally  low  blood  pressure;  the  causes 
being  pain,  hemorrhage,  fear  and  mental  distress  and 
sepsis. 

Long-continued  painful  sensations  irritate  or  over- 
stimulate  brain  cells  to  the  point  of  exhaustion.  For 
example,  the  shock  and  diminished  vitality  which 
accompany  severe  or  extensive  superficial  injuries, 
as  burns,  are  accounted  for  by  the  irritation  of  the 
many  sensory  nerves  in  the  skin,  each  one  carrying 
its  message  of  pain  to  the  overwrought  brain  and 
causing  changes  in  the  cells  of  brain  centers.  Struc- 
tural changes  are  found  also  in  the  cells  of  the  liver 
and  adrenal  bodies,  and  in  addition,  engorgement  of 
veins  of  the  portal  system  so  that  the  blood  is  not 
properly  returned  to  the  heart. 


28  WAR  NURSING 

Hemorrhage  will  contribute  to  these  same  changes 
and  will  be  considered  later  (see  p.  30).  As  an 
immediate  effect  of  these  disturbances  the  blood 
pressure  falls. 

The  powerful  effect  of  psychic  conditions  we  can 
not  estimate,  but  we  know  that  every  strong  emotion 
affects  the  whole  circulatory  apparatus  and  that  the 
recognition  of  sudden  impending  danger  will  blanche 
the  face  of  the  bravest.  Consider  then,  the  state  of 
the  helpless  wounded  man  whose  injuries,  although 
severe,  have  not  rendered  him  unconscious.  He  may 
not  knowingly  be  afraid,  but  in  his  helplessness  he 
can  not  forget  that  every  moment  may  bring  a  mes- 
sage of  fatal  ending,  and  unavoidably  he  thinks  of 
others  far  away  of  whose  welfare  he  may  not  be  sure. 
The  inevitable  physical  depression  so  caused  prob- 
ably adds  to  shock,  and  certainly  retards  recovery 
from  it. 

No  one  can  blot  out  the  memory  of  his  terrors  no 
remove  the  cause  of  his  apprehension,  but  a  calm  and 
cheerful  manner  on  the  part  of  those  who  are  caring 
for  him  and  a  word  of  encouragement  now  and  again 
may  help  toward  restoring  his  moral  balance  until 
he  regains  his  lost  confidence. 

Sepsis  rapidly  undermines  the  system  and  when 
already  established  is  undoubtedly  an  influential 
contributor  to  shock.  It  always  damages  the  heart 
muscle  and  wastes  the  vital  powers,  and  by  inter- 


DANGERS   OF  INFECTION.      HEMORRHAGE          2g 

faring  with  normal  metabolism  it  throws  down  Na- 
ture's defenses.  This  will  appear  in  cases  which  for 
one  reason  or  another  have  been  beyond  the  reach  of 
proper  care  at  first.  The  prevention  of  sepsis  begins 
with  the  first  dressing;  it  will  secure  to  the  man  his 
best  chance  when  he  meets  trying  ordeals  such  as 
hemorrhage,  or  operation  so  often  accompanied  by 
shock. 

Nursing  then  will  early  have  to  do  with  shock. 
Remember  the  primary  causes — pain,  hemorrhage, 
mental  distress,  sepsis,  all  resulting  in  lowered  blood 
pressure  and  lack  of  general  functional  activity. 

Treatment  of  Shock. — The  patient  is  cold  and 
clammy — make  him  warm  and  dry  if  possible,  by 
the  application  of  heat  and  friction  to  extremities. 
The  abdominal  vessels  are  engorged — elevate  the 
foot  of  the  bed  to  send  the  blood  toward  the  heart 
that  it  may  be  distributed  to  exhausted  brain  centers. 
If  the  pain  is  severe,  morphia  may  be  ordered  at 
once ;  this  aids  also  in  diminishing  the  flow  of  blood  in 
hemorrhage,  thus  serving  two  purposes. 

If  it  is  possible  for  the  nurse  to  keep  her  stock  of 
hypodermic  tablets  full,  she  will  be  ready  to  act  on 
the  instant  of  receiving  the  surgeon's  order,  a  service 
which  will  be  appreciated. 

There  may  be  minor  causes  of  discomfort  which  in 
the  exhausted  condition  of  the  patient  he  can  not  well 
bear,  thus  making  unnecessary  demands  upon  his 


30  WAR  NURSING 

already  diminished  vitality.  Is  he  lying  upon  dis- 
arranged clothing?  or  blankets  "all  in  a  hump?" 
Can  his  position  be  changed  for  the  better,  head  sup- 
ported, wounded  parts  protected  from  pressure? 
Are  bandages  too  tight,  or  dressings  dry  and  irritat- 
ing? It  is  possible  that  the  pain  of  a  tight  bandage 
may  be  made  more  endurable  by  releasing  a  single 
turn  here  and  there,  or  by  severing  a  cutting  edge 
(this  to  be  done  only  by  one  who  knows  whether 
any  danger  of  hemorrhage  or  disturbance  of  dres- 
sings can  possibly  result) ;  frequently  the  insertion  of 
a  bit  of  cotton  will  give  temporary  relief  from  rough- 
ened dressings  and  protect  a  part  from  irritation. 

At  once  it  must  be  determined  whether  a  tourni- 
quet has  been  applied  and  is  still  in  position;  if  this 
is  the  case  it  must  be  reported  promptly,  as  the  pain 
so  caused  may  well  add  to  the  shock  from  which  the 
man  is  suffering. 

NOTE. — Attendants  should  be  cautioned  against 
rough  or  careless  handling  of  the  patient  (always 
inexcusable),  especially  if  the  case  is  one  of  com- 
pound fracture  of  the  femur,  as  this  injury  appears 
more  often  than  others  to  be  accompanied  by  shock 
when  the  limb  is  disturbed. 

If  hemorrhage  is  present  it  will  add  rapidly  to  the 
effect  of  pain. 
The  nurse  who  is  holding  a  responsible  position, 


HEMORRHAGE  31 

must  train  herself  to  rapid  inspection  and  to  see 
everything  at  once. 

She  will  discover  without  thinking,  whether  the 
escaping  blood  be  arterial,  with  its  bright  red  spout- 
ing stream;  venous,  with  its  darker  steady  flow,  or 
capillary,  with  its  constant  oozing,  and  select  the 
measures  to  be  used  in  accordance  with  the  indica- 
tion, remembering  that  arterial  blood  is  flowing  from 
the  heart  and  must  be  checked  above  the  wound, 
while  the  venous  blood  is  flowing  toward  the  heart 
and  pressure  should  be  applied  on  the  distal  side  of 
the  wound;  for  capillary  oozing  she  will  quickly 
apply  compresses  with  direct  pressure  upon  the 
surfaces. 

Review  quickly  and  look  for,  signs  of  internal 
hemorrhage : — the  rapidly  increasing  pulse  with 
diminished  volume  and  easily  compressible;  the 
pallor  of  the  features  with  cyanosis  appearing, 
especially  about  the  lips,  eyelids,  fingers;  the  peculiar 
gasping  respiration  caused  by  air  hunger,  the  rest- 
lessness of  the  patient  as  he  gasps  for  breath,  and 
the  fall  of  the  body  temperature.  These  signs  all 
indicate  the  escape  of  a  large  quantity  of  blood  be 
the  hemorrhage  external  or  internal.  If  external 
it  will  probably  be  discovered  before  it  is  sufficiently 
serious  to  cause  the  symptoms;  but  if  internal  it 
will  hardly  be  discovered  until  they  appear. 


32  WAR  NURSlXt; 

Cause  of  Ak  Hunger, — The  diminished  quantity  of  blood 
is  unable  to  appropriate  sufficient  oxygen  from  the  air  in 
the  lungs  to  satisfy  the  wants  of  the  patient's  body.  Con- 
sequently, the  unusual  effort  of  respiration  appears  and 
the  necessity  for  abundant  fresh  air  is  imperative. 

Other  symptoms  which  result  from  the  diminished  quan- 
tity of  blood,  are  dimness  of  vision  and  ''roaring"  in  the  head; 
(the  latter  is  quite  different  from  the  sensation  described  as 
roaring  in  the  ears,  being  far  more  overpowering). 

NOTES. — In  a  military  hospital  it  is  more  than  ever 
important  that  everything  should  be  in  readiness  for 
meeting  the  occurrence  of  sudden  hemorrhage:  soft 
absorbent  material;  blocks  or  some  substitute  for 
elevating  the  bed;  hypodermic  syringes  with  tablets; 
ice  if  possible,  not  forgetting  that  hot  bottles  may 
be  needed  later;  blankets;  bandages;  appliances 
for  administering  saline  or  glucose  solutions,  etc. 

The  character  of  the  cases  under  treatment  may 
forbid  a  certain  freedom  of  action  in  dealing  with 
hemorrhage,  for  example — the  points  of  compression 
of  main  arteries  are  not  always  accessible,  owing  to 
extensive  damage  of  tissues  in  their  neighborhood; 
nor  is  it  always  practicable  to  exercise  autocompres- 
sion  by  forced  flexion  of  joints. 

In  the  case  of  visible  external  hemorrhage  it  is 
well,  as  soon  as  it  is  discovered,  to  so  dispose  what- 
ever loose  absorbent  material  may  be  at  hand  that 
it  will  receive  the  escaping  blood  and  thus  give  in- 


HEMORRHAGE  33 

formation  of  its  volume  and  whether  it  is  increasing 
or  diminishing  in  amount  (serious  hemorrhage  will 
soon  appear  through  saturated  dressings).  Try  to 
make  the  blood  run  away  from  the  wound  by  ele- 
vating the  part  involved  if  the  location  of  the  bleed- 
ing and  character  of  the  dressings  will  allow,  or  with 
the  same  proviso,  seek  to  exert  pressure  upon  or 
above  it;  put  ice  to  the  surface  and  to  the  bleeding 
vessels.  Severe  hemorrhage,  except  from  injuries 
to  the  head  and  neck,  calls  for  elevation  of  the  foot 
of  the  bed. 

These  precautions  taken,  further  measures  are  in 
order  for  meeting  the  lowered  blood  pressure  which 
occurs  in  both  hemorrhage  and  shock.  General 
compression-bandaging  of  the  extremities  will  coun- 
teract in  part  the  inequality  of  circulation  and  by 
driving  the  blood  from  the  relaxed  surface  vessels 
to  those  nearer  the  heart,  will  give  the  heart  some- 
thing to  work  upon.  To  replace  the  volume  of 
fluid  lost,  be  ready  for  the  introduction  of  normal 
salines  (see  p.  35)  (with  probably  the  addition  of 
adrenalin  or  pituitary  extract).  Prepare  for  hypo- 
dermic medication  with  promptness,  as  morphia, 
adrenalin  or  pituitary  extract  will  be  needed. 

NOTE. — The  use  of  pituitary  extract  in  shock  is 
based  upon  the  belief  that  it  will  cause  contraction  of 
the  vessels  of  the  abdominal  viscera,  which  are  in  a 
state  of  engorgement. 


34  WAR  NURSING 

Resume. — Nursing  then,  in  surgical  shock,  deals 
with  a  nervous  system  exhausted  by  pain,  fear  and 
apprehension,  and  probably  sepsis.  The  measures 
instituted  must  control  the  pain  and  minimize  the 
suffering.  Secure  rest  if  possible  in  the  most  com- 
fortable position  which  can  be  arranged,  as  the 
patient  may  be  obliged  to  lie  still  for  hours;  be  ready 
to  carry  out  orders  instantly;  protect  him  from  ex- 
citement and  signs  of  alarm;  make  him  feel  that  he 
is  in  good  and  safe  hands. 

What  not  to  do.  Do  not  give  stimulants,  neither 
alcohol  nor  strychnin  nor  digitalis.  Having  given 
morphia,  pituitary  extract  or  adrenalin,  put  away 
the  hypodermic  syringe  and  depend  upon  aromatic 
ammonia,  ice  pebbles  infrequently  given;  mustard 
over  the  heart. 

Remember  fresh  air,  bandages,  and  elevation; 
if  hemorrhage  is  present  have  in  mind  that  when 
bleeding  from  head,  neck,  or  chest,  the  patient  may 
be  placed  in  a  semi-upright  position,  the  heart's 
action  being  carefully  watched  meanwhile.  Secure 
fresh  air,  administer  oxygen  if  necessary.  Re- 
member at  the  same  time  that  calmness  need  not 
interfere  with  celerity  and  is  most  important  for  the 
sake  of  the  patient;  if  he  sees  that  his  nurse  meets  the 
emergency  which  confidence,  his  own  fears  will  be 
allayed  and  his  chances  will  be  improved  because 
he  is  to  that  extent  relieved  from  worry  about 


DANGERS  OF  INFECTION.      HEMORRHAGE          35 

himself.     It  is  said  that  soldiers  fear  hemorrhage 
more  than  gunfire. 

If  internal  hemorrhage  is  suspected  send  for  the 
surgeon  by  the  speediest  messenger  available. 

INTRODUCTION  OF  SALINE  SOLUTIONS 

This  will  be  done  by  the  intravenous  route,  if  ur- 
gent ;  subcutaneously  (hypodermoclysis) ,  if  less  urgent ; 
by  rectum  (enter ocly sis)  if  time  will  allow.  The  latter 
method  is  preferable  if  circumstances  permit  be- 
cause less  painful;  raise  and  support  the  buttocks, 
introduce  the  tube  well  beyond  the  rectal  sphincters 
and  control  the  rate  of  the  flow,  that  it  may  be  very 
slow.  With  low  blood  pressure  there  is  very  little 
absorption  and  time  must  be  allowed. 

If,  in  intravenous  infusion  the  flow  is  rapid,  the 
fluid  will  ooze  through  the  vessel  walls  and  accu- 
mulate in  the  loose  tissues  about  the  vessels,  as  for 
example,  in  the  abdomen,  where  the  cedematous 
condition  thus  resulting  has  been  known  to  cause 
embarrassment  of  respiration  by  pressure  upon  the 
under  surface  of  the  diaphragm,  thus  preventing  its 
contraction  to  secure  free  entrance  of  air  into  the 
lungs. 

The  temperature  of  the  solution  should  be  kept  at 
112°  in  the  funnel.  This  devolves  upon  the  nurse. 
Some  surgeons  advocate  in  certain  cases,  the  ad- 


36  WAR  NURSING 

ministration  of  a  half  pint  each  hour,  repeated  several 
times. 

The  introduction  of  saline  solution  by  hypoder- 
moclysis  or  subcutaneous  infusion  is  familiar  to  all 
trained  nurses  and  need  not  be  minutely  described. 
To  the  nurse  will  probably  fall  the  care  and  prepara- 
tion of  the  appliances  needed,  as  containers  with 
solution,  tubing  and  glass  connection  tube,  sharp 
needles,  sponges,  the  indispensable  testing  ther- 
mometer, etc.,  and  materials  for  sealing  the  punc- 
ture. All  to  be  prepared  and  handled  with  sterile 
precautions. 

The  maintenance  of  the  temperature  in  the  flasks 
will  be  her  duty  and  in  the  absence  of  the  usual  facili- 
ties she  may  have  to  exercise  ingenuity;  for  instance, 
by  careful  wrapping  with  non-conducting  materials, 
or  the  suspension  of  hot  water  bags  around  the  flasks. 
Also,  she  must  watch  the  flask  to  be  sure  that  it  does 
not  become  completely  empty,  allowing  air  to  enter 
the  needle.  The  temperature  and  quantity  to  be 
used  will  be  prescribed  (usually  about  500  cc.). 

For  intravenous  infusion,  a  scalpel,  special  needles, 
ligature  silk  and  aneurysm  needle,  etc.,  are  needed 
in  addition,  as  well  as  forceps,  sponges,  and  sterile 
protectors,  as  for  minor  operations.  The  tempera- 
ture of  the  fluid  must  be  scrupulously  maintained 
and  the  rate  of  the  flow  controlled.  More  than  ever 
it  is  important  to  prevent  the  possibility  of  the  en- 


DANGERS   OF  INFECTION.      HEMORRHAGE          37 

trance  of  air  into  the  needle,  as  a  fatal  result  would 
probably  follow. 

NOTE. — Solutions  of  Glucose,  usually  of  the  strength 
of  5  per  cent.,  are  sometimes  used  in  place  of  the 
saline. 


CHAPTER  V 
SURGICAL  DRESSINGS 

The  tremendous  number  and  variety  of  wounds 
in  the  present  war,  necessitating  the  care  of  many 
thousands  of  men  at  one  time,  and  the  entirely  new 
situations  created  by  the  character  of  modern  war- 
fare have  led  to  an  amount  of  labor  and  research 
heretofore  unknown,  not  alone  in  order  that  lives 
may  be  saved  but  that  the  medical  profession  may 
be  true  to  its  traditions,  never  stronger  than  to-day, 
that  the  best  methods  which  can  be  discovered  must 
always  be  sought,  and  the  best  service  in  its  power 
to  bestow  must  be  given.  This  obligation  presents 
itself  just  as  plainly  to  the  nurse  and  is  just  as  bravely 
met. 

Never  has  the  surgeon  had  to  face  greater  diffi- 
culties; never  has  he  recorded  more  brilliant  suc- 
cesses. To  accomplish  this  the  modern  pathological 
laboratory  has  contributed  so  largely,  that  it  is  not 
too  much  to  say  that  the  results  would  have  been 
long  deferred  without  it. 

Where  practically  every  wound  is  infected  the 
problem  of  antisepsis  has  of  necessity  received  un- 
usual attention  and  the  merits  of  different  substances 

38 


SURGICAL  DRESSINGS  39 

having  antiseptic  qualities  have  been  warmly  dis- 
cussed. Theory  and  practice  have  narrowed  down 
to  a  very  few  principles  and  proceedings.  The  'fact, 
not  new,  is  emphasized,  that  antiseptics  which  are 
strong  enough  to  be  antiseptic  must  be  used  with 
great  care,  especially  in  cavities  where  drainage  is 
not  free,  as  a  solution  which  injures  the  tissues  does 
more  harm  than  good  by  coagulating  the  albumen  of 
surfaces  and  forming  a  crust  which  confines  microbes. 
After  many  trials  and  much  discussion  the  tendency 
of  those  of  widest  experience,  however,  is  to  reduce 
the  problem  to  very  simple  terms  which  may  be  ex- 
pressed thus:  first,  how  to  secure  a  clean  wound; 
second,  how  to  give  Nature  a  chance  with  a  minimum 
of  interference,  since  Nature  after  all  must  do  the 
healing. 

The  following  is  a  brief  list  of  familiar  antiseptics 
among  many  newer  ones,  which  have  been  used  in 
the  present  war  for  their  chemical  and  germicidal 
action: 

Iodine,  2  per  cent,  solution  in  alcohol. 

Carbolic  acid,  2%  per  cent,  or  stronger  if  indicated 
(beware  of  the  coagulating  effect  of  strong  solutions) . 

Lysolj  i  drachm  to  the  pint. 

Bichloride  of  mercury,  1-20,  1-500  or  less. 

Potassium  permanganate,  2  per  cent. 

Hydrogen  peroxide,  pure  or  diluted. 

Hot  boric  acid_solution  (saturated) . 


40  WAR  NURSING 

These  all  depend  upon  chemical  action  for  produc- 
ing their  effects  and  their  value  lies  in  the  properties 
by  which  they  destroy  microbes  in  a  fresh  wound 
and  prevent  further  invasion.  They  may  well  be 
used  for  cleansing  purposes  (the  removal  of  dirt,  etc.) 
and  in  the  effort  to  prevent  sepsis  and  infection. 

To  these  must  be  added  hypochlorous  acid,  either 
in  the  form  of  gas  or  in  combination  as  a  hypochlorite 
in  solution,  which  has  both  germicidal  and  physical 
properties;  and  sodium  chloride  solutions  for  which 
similar  claims  are  made,  although  their  principal 
characteristics  are  physical. 

How  does  Nature  proceed  with  her  share  of  the 
work?  By  increasing  the  supply  of  material  with 
which  to  repair  the  damaged  part.  This  must  be 
obtained  through  the  source  of  all  nourishment  and 
growth,  namely:  the  blood;  it  is  provided  for  the 
purpose  in  the  form  of  lymph. 

Lymph  is  a  clear  saline  fluid  derived  from  the  blood,  from 
which  it  receives  its  freight  of  nutritive  substances;  it  is  very 
like  plasma,  retaining  many  of  the  constituents  dissolved  in 
the  plasma.  This  clear  fluid  passes  through  the  blood-vessel 
walls  into  the  minute  spaces  in  all  the  tissues  of  the  body 
(except  cuticle,  hair  and  nails).  It  has  a  circulation  of  its 
own  in  lymph  vessels,  bearing  lymph  cells  from  lymph  glands. 

Frcm  the  ruptured  spaces  and  vessels  of  a  wound, 
lymph  is  poured  freely  into  the  cavity,  the  surfaces 
of  which  it  bathes  and  thus  the  materials  for  repair 


SURGICAL  DRESSINGS  41 

or  healing  are  provided ;  not  only  this — the  irritation 
due  to  injury  causes  an  accelerated  flow  of  blood  and 
tissue  fluids  and  if  a  proper  outlet  is  available  the 
lymph  will  escape  from  the  wound  in  an  appreciable 
quantity;  in  other  words,  the  "drainage  is  good." 
A  continuous  flow  of  lymph  into  and  from  the  wound 
is  called  "lymph  lavage,"  which  is  now  recognized  as 
a  thing  of  great  importance  and  persistent  efforts 
have  been  made  to  find  remedies  which  will  assist 
this  outflow,  while  at  the  same  time  exerting  an  anti- 
septic action  without  damaging  the  tissues. 

Importance  of  the  Outflow  of  Lymph. — It  brings, 
by  the  tissue  cells  floating  in  it,  numerous  antibodies 
which  overcome  the  toxins  produced  by  microbes. 
It  also  directs  a  current  outward  from  the  wound 
surfaces  and  thus  discourages  absorption. 

Hypochlorous  Acid  and  Its  Use. — The  value  of 
this  antiseptic  has  been  demonstrated  by  Dr.  Alexis 
Carrel.  It  is  used  either  in  the  form  of  gas  or  in 
solution.  A  mixture,  carefully  measured  by  weigh- 
ing, of  calcium  chloride  or  " bleaching  powder"  with 
sodium  borate,  moistened  with  a  small  quantity  of 
water,  will  set  free  hypochlorous  acid  gas,  a  powerful 
antiseptic.  A  solution  is  made  by  adding  a  sufficient 
quantity  of  water  to  the  same  mixture,  the  measure- 
ments of  powder  and  water  being  strictly  accurate. 

This  is  "Dakin's  Solution"  so  called  because  as 
first  given  to  the  profession  it  was  worked  out  by  Dr. 


42  WAR  NURSING 

Dakin  as  a  practical  form  in  which  to  utilize  the 
antiseptic  qualities  of  hypochlorites.  Dr.  Carrel 
gave  to  the  powder  (or  tablet  made  of  the  same)  the 
name  Eupad;  to  the  solution  the  name  Eusol. 

This  formula  has  been  varied  from  time  to  time; 
some  surgeons  use  an  acid  solution  (anaerobes  do  not 
live  in  an  acid  medium),  others — an  alkaline,  while 
Dr.  Dakin  and  Dr.  Carrel — in  the  Dakin-Carrel 
treatment,  avoid  an  excess  of  either  quality.  The 
solution  now  used  by  them  is  made  according  to  the 
formula  of  Daufresne,  in  which  the  calcium  chloride 
or  "bleaching  powder"  is  combined  accurately  with 
both  sodium  carbonate  and  sodium  bicarbonate, 
making  a  nearly  neutral  product  which  contains 
from  .45  to  .5  per  cent,  of  sodium  hypochlorite; 
less  is  too  weak,  more  is  too  strong. 

The  Carrel  Technique. — All  badly  damaged  tissues 
as  skin,  muscle,  fat,  etc.,  are  carefully  cut  away  and 
loose  pieces  of  bone  removed  so  that  only  sound  tis- 
sues remain  (see  "  Excision,"  p.  72). 

The  skin  surrounding  the  wound  is  covered  closely 
with  layers  of  gauze  (two  or  more)  about  3  inches 
wide,  which  has  been  soaked  in  melted  sterile  petro- 
latum and  the  solution  is  then  introduced  through 
fine  rubber  tubes  which  are  attached  to  the  four 
branches  of  a  glass  distributor  (Fig.  i).  The  fluid 
is  conducted  to  this  through  a  rubber  delivery 
tube,  from  a  graduated  container  of  glass  (Fig.  2). 


SURGICAL  DRESSINGS 


43 


I^Cg^Zg^^^^^Myl 

TUir 


FIG.   I. — Carrel's  instillation  apparatus.    Extra  parts  which  may  be 
used  in  small  wounds. 

n 


FIG.  2. — Carrel's  instillation  apparatus.     The.  parts  described  in 
the  text  are  easily  identified. 


44  WAR  NURSING 

The  rate  of  the  flow  is  regulated  as  it  leaves  the  con- 
tainer, and  again  by  the  insertion  of  a  glass  connection 
which  allows  it  to  pass  very  slowly  and  through  which 
it  may  be  watched.  The  very  small  tubes  or 
"instillation  tubes"  6  mm.  in  diameter,  are  perforated 
on  four  sides  for  a  few  inches  of  their  distal  portion, 
and  the  end  of  each  is  securely  tied  with  silk  or  linen 
thread.  (By  removing  these  threads  the  tubes  may 
be  perfectly  cleaned,  which  could  not  be  done  if  they 
were  closed  like  a  catheter).  These  are  the  "Carrel 
tubes."  The  whole  assemblage  of  parts  constitutes 
the  Carrel  apparatus  used  for  the  Carrel  technique. 

The  size  of  a  wound  determines  the  number  and 
length  of  the  tubes,  attached  in  fours  to  the  four- 
branched  distributors.  A  sufficient  number  is  em- 
ployed to  reach  every  recess  of  the  wound  cavity. 
At  first  it  was  thought  necessary  to  wrap  them  in  fine 
bath  towelling,  to  prevent  them  from  slipping  about 
and  to  keep  the  fluid  in  contact  with  the  wound 
surfaces,  but  now  Dr.  Carrel  omits  the  towelling 
since  it  is  often  mechanically  irritating.  If,  however, 
the  wound  is  large  and  many  tubes  are  used,  a  little 
gauze  is  laid  loosely  about  them  to  prevent  them  from 
falling  together  or  "bunching."  Thus  the  fluid 
delivered  through  the  minute  holes  in  the  instilla- 
tion tubes,  is  brought  into  contact  with  the  entire 
wound  surface.  The  whole  is  then  covered  lightly 
with  gauze  wet  with  the  solution,  or  eusol. 


SURGICAL  DRESSINGS  45 

The  solution  is  allowed  to  flow  very  slowly,  the 
quantity  delivered  being  registered  on  the  walls  of 
the  container.  About  10  cc.  is  allowed  for  one  instil- 
lation of  four  tubes ;  the  fluid  will  reach  the  wound  sur- 
faces quite  fast  enough  by  oozing  through  the  tubes. 
In  about  2  hours  they  are  again  filled,  and  this  is 
repeated  at  the  same  interval  until  the  wound  is 
approximately  free  of  microbes  as  determined  by 
bacteriologic  examination. 

The  wound  is  inspected  daily  and  redressed  if 
practicable,  with  every  antiseptic  precaution;  no 
hand  touches  it  or  the  dressings.  At  the  redressing 
the  skin  is  cleansed  with  ether  to  remove  the 
petrolatum,  then  sponged  with  some  non-irritating 
alkaline  preparation  (neutral  solution  of  sodium 
oleate  is  recommended).  The  wound  also  is  very 
carefully  and  gently  sponged  with  the  same  and 
finally  with  eusol;  thus  wound  secretion  and  debris 
are  removed  and  all  is  ready  for  fresh  tubes  and 
solution,  as  before.  When  circumstances  forbid 
the  daily  redressing  the  gauze  covering  it  may  be 
changed  from  time  to  time. 

If  this  treatment  is  successfully  carried  out  recent 
severe  wounds  containing  septic  matter  may  become 
clean  in  from  three  to  five  days  and  then  closed  and 
sutured.  Precautions  are  taken  to  insure  drainage 
and  wounds  are  not  closed  while  any  infecting 
material  remains. 


4'6  WAR  NURSING 

It  is  claimed  that  the  action  of  the  solution  ex- 
tends a  short  distance  into  the  tissues  immediately 
surrounding  the  wound,  destroying  microbes  which 
have  gained  entrance  thus  far. 

A  satisfactory  way  of  dealing  with  a  perforating 
gunshot  wound  is  to  introduce  an  instillation  tube 
upside  down  in  the  whole  length  of  the  track.  The 
fluid  running  in  from  below,  oozes  through  the  open- 
ings in  the  tube  in  the  upper  part  of  the  wound  and 
gravitates  to  the  lower  opening,  thus  bathing  it 
throughout. 

Dakin's  solution  is  not  only  an  antiseptic  but  an 
agent  for  inducing  the  outflow  of  lymph  from  the 
tissues.  The  lymph  itself  has  a  remedial  action, 
inasmuch  as  it  contains  immune  bodies  which  have 
formed  in  response  to  the  presence  of  septic  material. 

NOTE. — Special  care  is  demanded  in  using  this 
remedy,  (i)  that  the  limb  or  part  be  disposed  in  a 
position  as  comfortable  as  possible;  (2)  that  the 
temperature  and  rate  of  flow  of  the  fluid  be  under 
observation  continually;  (3)  that  the  skin  be  pro- 
tected from  its  irritating  effects;  these  are  not  felt 
within  the  wound  where  the  albuminous  content  of 
the  natural  fluids  exerts  a  neutralizing  effect. 

The  method  just  described  is  that  of  interrupted 
irrigation  and  is  the  one  most  frequently  used. 
Another  is  by  continuous  irrigation  which  name 


SURGICAL  DRESSINGS  47 

explains  itself.  It  is  not  often  that  this  form  of 
application  is  adopted.  Drainage  must  be  care- 
fully maintained,  the  skin  being  well  protected,  and 
careful  provision  made  for  the  prevention  of  overflow 
and  for  keeping  the  clothing  and  bedding  dry. 

If  the  solution  causes  pain  it  will  be  due  to  one  of 
two  reasons;  it  is  either  too  strong  and  should  be 
diluted,  or  it  is  not  properly  made  and  is  too  alkaline. 

NOTE. — If  it  is  necessary  to  dilute  the  solutions, 
use  only  sterile  water. 

When  properly  made  it  is  not  irritating  to  wound 
surfaces  if  used  in  the  strength  of  .45  per  cent.; 
they  are  protected  by  the  reaction  of  normal  tissue 
fluids. 

A  simple  test  for  excessive  alkalinity  may  be  made  thus: 
"  take  20  cc.  of  the  solution  in  a  glass  and  add  without  stirring 
a  small  quantity  of  phenolphthalein  in  powder;  if  a  deep  red 
color  appears  the  presence  of  free  caustic  alkali  is  proved." 

Many  experiments  were  made  by  Dr.  Dakin  and 
Dr.  Carrel  before  they  adopted  this  solution.  As 
now  in  use  it  possesses  the  following  advantages: 

1 .  It  is  antiseptic  but  does  not  damage  the  tissues. 

2 .  It  is  non-toxic,  no  danger  is  to  be  apprehended 
from  absorption. 

3.  It  is  hyper  tonic  j  that  is,  the  concentration  of 
the  solution  is  greater  than  that  of  blood  serum  and 


48  WAR  NURSING 

tissue  fluids,  therefore,  it  produces  an  outflow  of 
lymph. 

4.  If  used  as  an  acid  solution  it  is  available  against 
anaerobic  bacteria  which  require  an  alkaline  medium. 

Applications  of  powder  or  tablet.  The  powder 
may  be  dusted  over  open  sores  and  lightly  covered; 
it  may  be  sprinkled  on  strips  of  gauze  used  for  drain- 
age; a  portion  may  be  placed  in  the  first  aid  dressing 
pad;  it  may  be  well  wrapped  in  gauze  and  placed 
in  a  wound  cavity. 

The  use  of  eupad  is  really  for  the  purpose  of  apply- 
ing hypochlorous  acid  gas — the  strongest  antiseptic 
which  can  be  used  quite  safely. 

By  contact  with  tissue  fluids  the  powder  is  suffi- 
ciently moistened  to  evolve  the  gas,  which  penetrates 
to  all  recesses  and  is  absorbed  to  some  extent  by  the 
surrounding  walls.  If  only  lightly  covered  it  may 
be  left  in  place  for  a  few  hours  (perhaps  six)  when  the 
less  irritating  solution  will  be  substituted. 

For  rapid  effect  on  very  foul  wounds  the  gas  may 
be  confined  in  the  cavity  by  covering  the  whole 
dressing  with  an  air-tight  material;  10  to  20  minutes 
is  usually  enough  of  this. 

NOTE. — The  powder  or  tablet  must  always  be 
separated  from  direct  contact  with  tissues,  particu- 
larly vessels  and  nerves,  which  would  inevitably  be 
injured  by  the  strong  gas  evolved.  Hemorrhage  or 
neuritis  or  both  might  be  caused. 


SURGICAL  DRESSINGS  49 

The  fact  that  nearly  all  wounds  in  the  present 
war  are  infected  and  the  serious  and  fatal  nature  of 
the  infections,  has  stimulated  an  unusual  amount  of 
research  with  the  hope  that  safe  disinfectants  might 
be  discovered.  The  importance  of  this  lies  in  the 
fact  that  the  tissues  of  the  body  are  more  easily 
affected  by  the  disinfectant  than  the  bacteria  them- 
selves, which  fact  alone  defers  the  process  of  repair 
in  the  wound.  In  the  use  of  the  Dakin-Carrel 
solution  the  indication  seems  to  be  well  met  for  the 
surfaces  in  the  wound  and  near  it,  if  frequently  re- 
newed as  in  the  technique  described,  but  a  disad- 
vantage accompanies  its  use  in  that  it  is  extremely 
irritating  to  the  skin.  (This,  however,  is  easily 
remedied  by  the  use  of  petrolatum.) 

A  chemical  action  takes  place  between  the  solu- 
tion and  the  tissue  fluids  in  the  wound  and  a  new 
substance  is  formed  called  chloramin,  which  is  said 
to  possess  a  germicidal  power  four  times  greater 
than  that  of  the  solution  itself.  Successful  attempts 
have  been  made  to  produce  and  utilize  identical 
compounds  having  the  same  effects,  and  the  benefit 
conferred  by  their  use  has  been  demonstrated  in 
the  Pennsylvania  Hospital  under  Dr.  LeConte 
and  others,  who  some  time  ago  reported  a  series  of 
one  hundred  and  sixty  cases  satisfactorily  treated. 

By  dissolving  these  substances  (chloramins)  in 
an  oily  medium  it  is  possible  to  keep  them  in  contact 


50  WAR  NURSING 

with  the  wound  surfaces  for  a  much  longer  time 
than  can  be  done  with  a  watery  solution.  The 
advantage  of  this  is  evident. 

The  solution  which  is  used  at  present  has  been 
christened  dichloramin-T;  the  medium  is  eucalyptol. 
It  is  said  that  a  10  per  cent,  solution  of  dichloramin-T 
in  eucalyptol  may  be  kept  in  a  colored  bottle  for  at 
least  one  month  with  very  slight  change. 

It  is  applied  to  the  wound  surface  in  the  form  of  a 
spray  after  the  removal  of  infected  and  devitalized 
tissues.  Deep  cavities  are  rilled  with  the  liquid  and 
drainage  afterward  provided  for.  The  high  per- 
centage of  disinfectant  contained  in  this  preparation 
renders  it  active  for  a  period  of  24  hours  because 
of  the  slow  liberation  of  the  germicide.  It  would 
appear  that  when  applied  with  strict  attention  to 
detail  it  is  not  only  less  expensive  than  the  D akin- 
Carrel  method  but  will  secure  healing  of  the  wound 
in  a  shorter  time. 

NOTES. — The  slow  elaboration  of  the  remedy 
makes  it  particularly  applicable  in  cases  that  can  not 
be  dressed  often  in  transportation. 

Dichloramin-T,  hypochlorites,  and  hypertonic  salt  ap- 
plications all  have  the  power  of  dissolving  dead  tissues. 

CAUTION. — If  used  near  a  vessel,  hemorrhage  may 
occur. 

A  similar  preparation,  called  chlorazene,  is  advo- 
cated by  those  who  are  familiar  with  its  effects. 


SURGICAL  DRESSINGS  51 

Many  other  antiseptic  applications  are  described, 
as  used  in  various  hospitals  under  the  care  of  medical 
men  of  the  different  nationalities  engaged  in  the 
war.  They  are  prescribed  in  the  form  of  pastes, 
powders,  etc.  These  are  particularly  valuable  when 
there  is  a  great  rush  of  patients  and  it  is  necessary 
to  send  them  on  rather  hastily. 

A  soap  dressing  has  been  used  with  great  success 
for  cleansing,  in  a  solution  made  by  25  grms.  of 
Castile  soap  in  a  liter  of  water.  Afterward  the 
wound  may  be  dressed  with  compresses  dipped  in 
a  somewhat  weaker  solution.  This  is  said  to  be  an 
invariably  painless  application,  and  very  efficient 
in  promoting  healing.  It  may  be  reapplied  on  the 
following  day  and  if  necessary,  for  a  few  days  in 
succession. 

A  mixture  of  dry  calcium  hypochlorite  one  part, 
and  pulverized  boric  acid  ten  parts,  is  used  as  a 
dusting  powder  for  fresh  wounds;  it  is  said  to  be  "a 
powerful  sterilizer"  and  to  ward  off  even  the  de- 
velopment of  gas  gangrene. 

A  paste  of  bismuth  and  paraffin  is  sometimes 
ordered,  containing  one  ounce  of  bismuth  with  two 
of  iodoform  and  paraffin,  to  make  a  thick  paste. 
This  has  been  christened  bipp  or  B.I.P.  The 
wound  is  rilled  with  the  paste  with  the  object  of 
sterilizing  it  and  this  object  is  apparently  accom- 
plished; as  the  wound  "need  not  be  often  dressed, 


52  WAR  NURSING 

sometimes  for  days!"  This  is  available  for  trans- 
portation cases  for  whom  redressing  is  difficult  en 
route. 

Picric  acid  (i  per  cent.)  has  been  used,  applied 
on  thin  gauze  with  no  other  covering.  A  weaker 
solution  may  be  carried  into  sinuses  by  syringing, 
and  still  weaker,  when  granulations  reach  the 
skin  level. 

Another  preparation  which  has  been  used  in  recent 
wounds  and  in  first-aid  dressings,  is  Mender  e^s 
balsam,  applied  directly  to  the  wound  in  cases  where 
the  injuries  are  extensive  and  the  question  arises  as 
to  the  patient's  ability  to  stand  operation.  Many 
cases  thus  treated  have  been  saved  for  later  opera- 
tion and  then  have  recovered,  according  to  reports. 

Of  course,  these  various  applications,  to  be  effica- 
cious, must  be  used  early  while  sterilization  of  the 
wound  is  still  possible. 

The  nurse  need  not  be  surprised  to  see  a  wound 
with  abundant  drainage. and  doing  well,  which  has 
been  treated  with  pulverized  sugar.  It  is  stated 
that  more  than  fifty  surgeons  have  successfully 
used  this  remedy.  The  degree  of  lymph  lavage  is  so 
great  that  the  wound  does  not  need  redressing  at 
once,  being  washed  from  within.  It  appears  to 
be  especially  valuable  in  its  power  to  stimulate 
secretions,  thus  diluting  and  washing  out  the  pus 
when  it  is  present. 


SURGICAL  DRESSINGS  53 

Fortunately  the  sugar  obtained  in  the  market  is 
reasonably  free  from  infective  organisms. 

NOTE. — Laboratory  experiments  are  reported  to 
have  proved  that  the  bacillus  of  gas  gangrene  can  not 
grow  in  a  60  per  cent,  solution  of  saccharose.  It 
may  grow  in  broth  containing  40  per  cent,  or  even 
50,  but  never  in  the  stronger  solution — 60  per  cent. 

A  method  which  may  be  used  at  the  first  dressing 
station  is  a  modification  of  the  Carrel-Dakin  treat- 
ment without  the  apparatus  used  by  Dr.  Carrel. 
If  the  nurse  finds  that  a  wound  contains  a  loose  bag 
with  something  soft  within,  it  will  be  accounted  for 
as  follows:  A  number  of  pieces  of  agar  are  placed  on 
a  square  of  gauze  which  is  drawn  up  into  a  loose 
bag  with  the  edges  tied  together.  This  bag  is  placed 
in  the  wound  with  the  corners  of  the  gauze  lying 
free  outside.  It  is  then  thoroughly  wetted  with  some 
antiseptic  solution,  often  Dakin's  solution.  This 
causes  the  agar  to  swell  and  spread  the  wound,  so 
that  the  recesses  are  all  opened  and  the  disinfecting 
application  is  in  contact  with  the  tissues  throughout. 
The  disinfectant  is  added  anew  every  two  or  three 
hours,  or  it  could  be  supplied  with  a  Carrel  tube  in 
a  continuous  drip.  Drainage  is  provided  at  the  low- 
est point  of  the  cavity.  This  also  is  a  practical 
early  dressing  for  patients  who  must  be  transported 
at  once.  Results  are  said  to  have  been  "  realized 
beyond  the  fondest  dreams." 


54  WAR  NURSING 

Flavine  is  another  preparation  which  is  warmly 
advocated  by  many.  It  is  claimed  that  its 
special  merit  lies  in  these  facts:  first,  it  retains 
its  antiseptic  properties  in  the  presence  of  blood 
serum;  second,  it  is  nontoxic  to  tissue  cells;  third, 
the  degree  of  concentration  favors  the  outflow  of 
lymph. 

Treatment  with  saline  solutions  has  been  devel- 
oped by  English  surgeons  who  find  it  entirely  satis- 
factory in  their  hands.  It  is  not  claimed  that  it  is 
superior  in  itself,  but  that  it  is  effective  without  cer- 
tain disadvantages  which  accompany  the  use  of 
.antiseptics. 

Both  the  strong  or  hyper  tonic  and  the  normal  or 
isotonic  solutions  are  used,  prepared  with  care 
to  secure  proper  concentration  and  sterility;  also 
the  dry  salt  is  employed  in  powder  or  in  tablet. 
Antiseptics  are  employed  in  the  first  cleansing  of  a 
wound  but  the  hypersonic  saline  solution  immediately 
thereafter,  for  securing  lymph  lavage  upon  which 
the  success  of  the  treatment  mainly  depends. 

The  strength  of  the  solution  used  is  at  first  .5  per 
cent.,  but  after  a  suitable  time  this  is  reduced  to  .85 
per  cent.,  which  is  normal  or  isotonic. 

The  theory  upon  which  the  technique  has  been 
worked  out  is  stated  somewhat  as  follows:  The  aim 
of  treatment  is  to  promote  healing  by: 

First. — Removing  or  destroying  bacteria. 


SURGICAL  DRESSINGS  55 

Second. — Establishing  free  outflow  of  tissue  fluids, 
thus  bringing  fresh  antitoxin  and  immune  bodies  to 
neutralize  toxins  and  overcome  bacteria  in  the  wound. 

Third. — Securing  the  depletion  of  tissues  by  the 
quick  removal  of  exudative  fluids,  thus  relieving 
vascular  engorgement  and  pressure,  both  of  which 
contribute  to  gangrene. 

NOTE. — All  deep  raw  wounds  caused  by  high  ex- 
plosives and  missiles  of  various  kinds,  present  in  their 
depths  tissues  more  or  less  devitalized.  It  is  thought 
that  a  strong  purely  antiseptic  solution  may  hinder 
their  recovery  to  a  normal  condition,  as  all  anti- 
septics are  at  least  slightly  toxic  to  the  tissues  with 
which  they  are  in  contact  and  thus  microbic  inva- 
sion is  favored. 

Further  claims  are:  A  saturated  solution  of  sodium 
chloride  will  kill  bacteria. 

A  5  per  cent,  or  even  2)^  per  cent,  solution  will 
inhibit  their  growth. 

An  .85  per  cent,  (the  normal  solution)  does  not  kill 
bacteria  in  the  wound  but  encourages  the  emigration 
of  leucocytes,  and  of  phagocytosis  by  the  aid  of  the 
immune  bodies  provided  by  "  lymph  lavage." 

Methods  of  Application. — By  irrigation,  soaks  and 
drains,  compresses,  baths. 

NOTE. — Both£«s0/  and  hypertonic  solution  are  said 
to  prevent  coagulation  of  wound  discharges  and  pro- 
mote the  separation  of  sloughs  lying  in  the  wound. 


56  WAR  NURSING 

For  irrigation,  solutions  of  varying  strengths  are 
used  continuously  by  means  of  a  special  apparatus 
described  as  follows: 

The  rose  irrigator  (Fig.  3). — This  is  similar  in 
principle  to  the  Carrel  tubes.  It 
consists  of  a  good-sized  test  tube 
open  at  both  ends  and  packed  with 
gauze  through  which  the  solution 
flows  at  a  very  slow  rate.  A  rub- 
ber cap  with  four  fine  flexible  tubes 
depending  from  it  is  placed  over 
the  lower  end  of  the  test  tube  or 
distributor.  The  solution  is  held  in 
a  graduated  glass  container,  from 
which  it  is  conveyed  to  the  gauze- 
filled  tube  and  thence,  by  means  of 
the  four  small  tubes,  it  is  distributed 
throughout  the  wound. 

For  a  large  and  deep  wound  with 

FIG.    3.— The  .  °    -  r    \. 

rose  irrigator   of    much  mutilation   of    tissue  one  or 
?Jr.   ^mroth    more  of  these  four- tube  distributors 

Wright.     (After  .    . 

Hull.)  may  be  used.     For  an  injury  of  less 

extent  a  single  tube  will  suffice. 
For  drainage,  strips  of  gauze  or  loosely  woven  cot- 
ton bandaging  is  disposed  in  the  wound  and  car- 
ried to  a  basin  of  solution  placed  at  least  three  feet 
lower.  To  insure  contact  with  every  bit  of  a  large 
cavity,  gauze  wet  with  the  solution  is  loosely  packed 
around  the  tubes. 


SURGICAL  DRESSINGS 


57 


The  irrigation  is  continuous,  but  not  to  the  point 
of  depriving  the  patient  altogether  of  sleep  or  rest. 
It  may  be  suspended  at  times  for  this  reason,  the 


FIG.  4. — Combination  of  delivery  tube  and  cigarette  drain. 
The  cigarette  stiffened  with  aluminum  and  having  rubber  tubing 
attached,  lies  within  the  wound.  The  solution  is  conveyed  to  the 
wound  by  the  tube  A,  while  drainage  is  secured  by  means  of  the 
free  end  of  the  bandage  B,  which  belongs  to  the  cigarette.  (After 
Hull.) 

wound  being  covered  meanwhile  with  gauze  wet  with 
saline  solution. 

NOTE. — In  all  irrigations  the  provision  for  drain- 
age is  a  measure  of  prime  importance.  It  is  one  of 
the  basic  principles  upon  which  the  success  of  the 


58  WAR  NURSING 

treatment  depends.  This  is  usually  secured  by  gauze 
or  bandage  strips  or  by  tubing  leading  out  from  the 
wound,  but  whatever  device  is  adopted  it  must  act 
perfectly. 

A  useful  device  is  the  stiffening  of  the  small  tubes 
with  fine  strips  of  metal  (aluminum  is  used)  which 
render  them  easily  adjustable  to  the  depth  and  direc- 
tion of  wounds. 

A  combination  of  delivery  tube  and  capillary 
drain  is  described  and  its  application  may  easily  be 
understood  by  referring  to  the  illustration  (Fig.  4). 
A  narrow  strip  of  aluminum  is  wrapped  with  bandage 
and  rubber  sheeting  like  a  cigarette  drain,  with  the 
bandage  longer  by  12  inches  or  more  than  the  com- 
pleted cigarette.  A  long  fine  rubber  tube  an  eighth 
of  an  inch  in  diameter  is  attached  along  the  side  of 
the  cigarette.  The  drain  with  tubing  is  inserted  to 
the  depth  of  the  wound  and  bent  over  the  edge  so  that 
it  will  remain  in  place,  while  the  free  bandage  is  carried 
into  a  basin  of  the  solution  placed  at  a  lower  level. 
The  rubber  tube  conducts  the  solution  into  the 
wound,  the  capillary  drain  acting  as  a  siphon,  con- 
veys it  away.  Any  desired  number  of  these  capil- 
lary cigarette  drains  may  be  used  in  a  wound. 

As  with  Dakin's  fluid,  a  perforated  wound  is  made 
to  drain  most  efficiently  by  reversing  the  insertion 
of  the  delivery  tube  and  causing  the  bandage  to  drain 
from  the  upper  opening  downward  through  the  track. 


SURGICAL  DRESSINGS 


59 


By  many  this  dressing  is  considered  inconvenient 
because  of  the  danger  of  wetting  the  clothing  of  the 
patient,  or  the  bedding,  but  this  difficulty  need  not 
exist  in  competent  hajnds. 

Figure  5  represents  a  device  which  will  confine 
the  overflow  from  continuous 
irrigation  to  a  limited  area. 
Rings  of  cotton  encircle  the 
limb,  and  are  covered  with  a 
preparation  of  gelatine  and 
formalin,  which  is  both  water- 
proof and  flexible.  This  can  be 
molded  over  the  cotton,  and 
when  dry  it  seals  the  barrier 

,         ,  . 
tO  the  SKin. 

Strength  of  Saline  Solutions 

and  their  Effect  on  Bacteria.  —  As  already  stated,  a 
saturated  (or  10  per  cent.)  solution  kills.  One  of 
from  5  per  cent,  down  to  2%  inhibits  their  growth. 
.85  per  cent,  does  neither,  but  favors  emigration  of 
leucocytes  and  phagocytosis. 

Applying  these  facts  to  the  treatment  of  wounds 
the  reasons  for  the  use  of  different  percentages  will 
be  understood.  For  a  very  septic  wound  a  beginning 
may  be  made  with  a  5  or  even  a  10  per  cent,  solu- 
tion. After  a  time  the  wound  begins  to  clean  and 
the  patient  begins  to  complain.  The  strength  will 
then  be  reduced  gradually  to  that  of  the  normal  or 


FIG.  5.  —  Irrigation  bar- 
rier.     (After  Hull.) 


60  WAR  NURSING 

isotonic  solution.  Now  a  whitish  film  upon  the  sur- 
faces will  show  the  invasion  of  leucocytes  and  they 
with  the  antibodies  in  the  lymph  will  meet  any  bac- 
teria which  may  gain  entrance,. 

Again,  attention  is  called  to  the  importance  of 
lymph  lavage:  It  carries  out  waste  products,  it 
washes  away  microbes  and  small  bits  of  softened 
tissues,  it  removes  lymph  itself  from  the  wound  when 
the  antibodies  which  it  brought  have  become  used 
up,  and  it  encourages  the  flowing  of  lymph  with  fresh 
active  antibodies. 

Other  Methods  of  Use. — The  wound  may  be 
packed  (always  loosely)  with  gauze  which  has  been 
soaked  in  concentrated  salt  solution  and  dried. 
Vigorous  osmosis  is  set  up  and  a  profuse  outflow 
of  lymph.  The  gauze  must  touch  every  part  of  the 
wound  surface. 

Tablets  of  salt  wrapped  securely  in  gauze  are  used 
in  the  same  way,  that  is,  inserted  into  the  wound, 
with  the  precaution  that  the  tablet  itself  does  not 
come  in  contact  with  the  tissues.  It  would  un- 
doubtedly cause  sloughing. 

Col.  H.  M.  W.  Gray  has  devised  the  following 
method  to  enclose  powdered  salt  in  long  slender  sacs 
made  from  cotton  bandaging:  Between  two  layers 
of  bandaging  four  of  gauze  are  placed.  The  whole  is 
then  folded  upon  itself  and  the  edges  are  sewn  to- 
gether. The  sac  should  be  at  least  12  inches  long. 


SURGICAL  DRESSINGS  6 1 

This  is  filled  with  salt  to  a  depth  corresponding  with 
the  depth  of  the  wound  only;  the  remaining  unfilled 
portion  of  the  sac  is  to  hang  from  the  wound  and  act 
as  a  drain. 

NOTE. — Again,"  a  matter  of  first  importance  is  free 
drainage.  A  septic  wound  is  never  closed.  It  must 
drain.  It  is  proved  by  experiment  that  ordinary 
cotton  bandage  will  convey  more  than  a  pint  of 
fluid  in  an  hour  to  a  basin  placed  at  a  lower  level. 

Sacs  of  various  sizes  and  lengths  are  made  to 
fit  various  tracks  and  cavities;  within  the  wound 
they  are  separated  by  loose  gauze.  Drip  irrigation 
by  fine  rubber  tubing  attached  to  the  sides  of  the 
sac  may  be  carried  out  if  desired  in  selected  cases. 
It  is  found  that  the  sacs  may  be  left  in  place  for 
several  days  if  they  can  not  be  conveniently  re- 
moved and  replaced. 

The  use  of  salt  sacs  like  that  of  salt  tablets,  with- 
out the  addition  of  water,  will  cause  moistening  of 
the  wound  by  the  tissue  fluids  and/ree  lymph  lav  age. 

NOTES. — A  rise  of  temperature  may  follow  the 
removal  of  a  salt  sac.  If  this  is  apprehended,  irri- 
gate the  wound  for  a  few  hours  beforehand.  The 
temperature  is  due  to  irritation  of  a  dressing  too 
long  retained  or  rather  carelessly  removed. 

"If  a  wound  has  to  be  dressed  in  order  to  remove 
a  discharge  that  means  that  the  dressing  was  simply 
corking  it  in.  In  a  properly  dressed  wound  re- 


62  WAR  NURSING 

dressing  will  not  lower  a  high  temperature  nor 
elevate  a  low  one." 

Summary. — By  continuous  irrigation  Col.  Wright 
uses  salt  solutions  to  bring  fresh  antibodies  to  the 
wound;  and  by  interrupted  irrigation  Dr.  Carrel 
uses  Dakin's  solution  for  the  same  purpose.  The 
solutions  are  to  be  kept  in  continuous  contact, 
whether  by  irrigation,  bath  or  wet  dressings. 

Dry  salt  is  used  by  Col.  Wright  and  dry  powder 
(called  eupad)  by  Dr.  Carrel,  for  the  purpose  of 
making  a  strong  solution  with  the  patient's  own 
fluids  or  of  applying  hyperchlorous  acid  gas. 

In  both  methods  success  follows  painstaking 
devotion  to  detail,  and  strict  adherence  to  the  lines 
laid  down  for  carrying  out  the  treatment;  it  is 
accomplished  in  no  other  way. 

Observe  that  in  both  of  these  methods  of  dealing 
with  wounds,  emphasis  is  laid  upon  the  importance 
of  avoiding  tight  dressings  or  anything  like  plugging 
the  wound.  With  the  virulent  organisms  which  are 
dealt  with  in  the  present  war  this  would  be  disastrous. 
The  anaerobes  in  particular  would  flourish  abundantly 
in  confinement.  In  both  methods  the  patient  needs 
to  be  placed  in  a  position  of  rest  so  far  as  possible, 
as  the  treatment  is  to  him  monotonous  and  tire- 
some. The  nurse,  however,  has  plenty  of  occupa- 
tion in  keeping  temperature  and  flow  of  the  fluids 
at  the  right  points  and  in  devising  means  to  make 
him  comfortable. 


CHAPTER  VI 
THE  WOUNDED  MAN 

The  care  of  the  wounded  begins  on  the  battle- 
field, with  the  collection  by  stretcher  bearers  of  those 
who  have  fallen;  by  them  they  are  taken  to  the 
aid  post  or  first  dressing  station,  situated  in  some 
sheltered  place — often  a  dugout  and  very  near  the 
front  line  of  trenches.  Then  by  ambulance  bearer 
they  go  to  the  advanced  dressing  station  farther  back 
or  the  tent  division  of  the  field  ambulance  or  hospital 
so-called.  Still  farther  away  is  the  clearing  station 
or  evacuation  hospital  and  after  that  the  stationary 
and  base  hospitals  which  are  permanent  and  have 
hundreds  of  beds. 

Treatment  begins  in  the  first  dressing  station  or 
aid  post  where  only  imperative  needs  are  attended  to. 
First-aid  dressings  are  applied,  measures  for  check- 
ing hemorrhage  are  instituted  and  fractures  are 
immobilized  if  possible.  Some  minor  injuries  may 
be  quite  relieved  and  the  man  returned  to  his 
regiment. 

At  the  advanced  dressing  station  or  field  ambulance , 
measures  already  instituted  are  perfected  so  far  as 
possible,  wounds  are  dressed,  splints  applied,  stimu- 

63 


64  WAR  NURSING 

lants  given  and  some  further  measures  (necessarily 
incomplete)  are  taken  to  prepare  the  patient  for 
further  transportation  by  ambulance.  Only  the 
most  desperate  cases  may  tarry,  for  in  time  of 
battle  others  are  arriving  by  the  score  and  room  must 
be  made  for  them. 

To  neither  of  these  will  the  woman  nurse  go. 
Both  are  temporary  and  movable,  following  the 
army.  Here,  again,  some  men  may  go  back  to  the 
front  after  treatment  and  a  short  period  of  rest, 
having  only  minor  injuries,  but  most  are  sent  on 
by  ambulance  to  the  clearing  or  "evacuation" 
hospital.  (In  some  fields  a  main  dressing  station 
intervenes.)  Here  patients  are  arriving  hourly  in 
time  of  battle,  all  being  serious  cases  and  practically 
all  operative,  the  only  question  being  as  to  time 
and  the  endurance  of  the  patient — shall  he  be  oper- 
ated now,  or  after  going  on  to  the  base? 

The  clearing  hospitals  furnish  facilities  for  a  great 
deal  of  thorough  work,  although  if  stationed  near 
the  front  where  active  service  is  going  on  they  may 
be  more  or  less  temporary.  Many  of  the  patients 
need  operation  at  once  and  the  beds  are  filled  with 
serious  cases  of  every  description — all  surgical  and 
urgent.  In  these  stations  women  nurses  are  em- 
ployed and  greatly  are  they  needed. 

The  base  hospital  is  permanent  and  may  have  two 
thousand  or  more  beds.  Here  operations  are  done 


THE  WOUNDED  MAN  65 

daily  and  patients  are  kept  if  possible  until  they 
may  be  transported  "over  seas"  or  distributed 
to  sanitoria,  according  to  their  needs. 

Although  experience  in  temporary  hospitals  fur- 
nishes constant  thrills  and  excitement,  that  in  the 
more  permanent  institutions,  if  less  exciting,  is 
more  satisfactory  in  the  end,  as  one  can  there  see 
the  later  results  of  one's  work. 

In  either  place  there  is  no  limit  to  the  demands 
upon  the  nursing  staff  if  sympathy  and  the  desire 
to  help  prevail. 

It  is  not  practicable  to  outline  in  detail  the  work 
of  the  nurse,  as  quite  naturally  the  nature  of  the 
cases  and  the  circumstances  of  treatment  will  vary 
according  to  the  distance  from  the  battlefield. 

THE  CONDITION  OF  THE  WOUNDED  MAN 
Upon    inspection    of    a    newly    arrived    patient 
certain  things  must  be  observed  and  noted  for  im- 
mediate report: 


FIG.  6. — United  States  Army  field  tourniquet. 

First. — Is  a  tourniquet  in  position,  or  is  there 
constriction  by  tight  bandages?  (Fig.  6.) 

Second. — Has  a  wound  been  tightly  packed,  thus 
preventing  the  escape  of  blood  or  discharges? 


66  WAR  NURSING 

Third. — Has  it  been  plugged  for  the  suppression  of 
hemorrhage?  (Patients  should  be  examined  for 
these  possibilities  although  it  is  customary  to  send 
with  them  a  statement  as  to  whether  they  exist, 
but  this  may  have  been  lost  in  transit.) 

Fourth. — Are  evidences  of  general  sepsis  present? 
If  so,  secondary  hemorrhage  must  be  apprehended 
and  precautions  taken. 

Fifth. — Has  he  a  compound  fracture  of  the  femur 
or  of  the  humerus?  Here  again  hemorrhage  is  to 
be  apprehended  and  the  patient  must  be  carefully 
handled,  with  the  limb  supported,  and  made  as 
comfortable  as  possible. 

If  dressings  are  dry  and  adherent  they  may  be 
softened  by  means  of  compresses  wet  with  sterile 
saline  solution — or,  if  permitted,  by  gentle  irrigation, 
which  will  render  their  removal  easier  when  the  time 
for  that  arrives. 

When  the  wounded  man  reaches  the  nurse  he  is 
inevitably  suffering,  perhaps  exhausted  by  the  pain 
of  wounds  in  which  sepsis  may  have  already  de- 
veloped. He  has  had  neither  proper  food  nor  drink; 
the  suffering  caused  by  hurried  transportation  has 
added  to  that  of  the  wounds  themselves,  while  hemor- 
rhage and  shock  may  have  reduced  his  vitality  to  a 
still  lower  plane.  In  many  the  clothing  is  hopelessly 
contaminated;  the  nurse  will  long  to  remove  it  and 
order  a  bath,  but  must  wait.  She  will  see  at  a  glance 


THE  WOUNDED  MAN  67 

if  his  position  on  the  bed  is  as  near  to  comfortable 
as  the  nature  of  his  injury  will  permit  and  if  not 
she  will  endeavor  to  correct  it;  she  can  at  least  sup- 
port his  head  at  the  right  angle  and  release  him  from 
the  pressure  of  clothing  or  coverings  upon  sensitive 
parts. 

She  will  note  the  location  of  wounds  and  instruct 
her  assistants  how  to  move  or  lift  him;  at  the  same 
time  she  will  see  if  hemorrhage  is  or  has  been  occur- 
ring, as  evidenced  by  dressings  or  the  presence  of  a 
tourniquet.  The  latter  must  be  discovered  promptly 
and  the  condition  of  the  limb  examined,  that  any 
signs  of  threatened  gangrene  (as  swelling  with  dis- 
coloration) may  be  reported  at  once.  This  is  of 
such  importance  that  if  the  surgeon's  aid  can  not  be 
had  immediately  the  nurse  may  be  forced  to  act 
alone.  Endeavor  to  apply  pressure  directly  over 
the  artery  which  supplies  the  blood  in  the  wound. 
(The  safest  pressure  here  is  by  the  nurse's  own 
ringers  because  it  is  intelligently  applied),  then 
very  gradually  loosen  the  tourniquet  (but  not  on 
any  account  remove  it)  watching  for  the  appearance 
of  fresh  blood.  The  pressure  of  the  fingers  must 
control  that  if  it  appears.1 

Whenever  a  patient  is  badly  shocked  the  nurse  can 
institute  certain  measures  without  waiting  for  orders. 

1The  transportation  of  a  man  with  a  tourniquet  is  strictly 
forbidden  by  many  medical  officers  of  the  British  Army. 


68  WAR  NURSING 

She  can  give  him  a  hot  drink;  she  can  place  hot  bottles 
about  the  person,  carefully  avoiding  wounds,  as  the 
heat  may  encourage  hemorrhage.  She  can  protect 
him  from  unnecessary  interference,  placing  him 
with  the  head  lowered  and  proceeding  in  accordance 
with  general  directions. 

What  not  to  do.  She  is  not  to  give  him  hypodermic 
injections  of  strychnia  or  other  stimulant.  She  is 
to  be  ready  for  the  use  of  adrenalin  or  pituitary  ex- 
tract that  no  time  may  be  lost  if  they  are  ordered. 
(She  may  give  aromatic  ammonia,  or  weak  tea.) 

It  is  supposed  that  preparations  are  already 
made  for  the  introduction  of  saline  solutions  and  as 
this  will  probably  be  left  to  the  watchfulness  of  the 
nurse,  a  few  words  of  caution  are  here  repeated. 
The  maintenance  of  the  temperature  of  the  solution  is 
of  importance  and  also  the  rate  of  flow  which  should 
be  very  slow,  hardly  more  than  drop  by  drop. 
Intravenous  injection  will  be  supervised  by  the  sur- 
geon, but  there  also  the  watchfulness  of  the  nurse  in 
controlling  the  rate  of  the  flow  will  be  helpful.  This 
is  still  more  important  in  intravenous  injection 
because  it  is  found  that  the  fluid  quickly  leaves  the 
vessels  for  the  looser  tissues  in  which  they  are 
imbedded;  as  has  been  known  to  occur  in  the  abdo- 
men, where  great  quantities  of  loose  connective 
tissue  exist,  around  vessels  and  organs,  which  may 
receive  so  much  of  this  fluid  as  even  to  embarrass 


THE  WOUNDED  MAN  69 

respiration.  Remember  then  these  two  points — 
maintenance  of  the  proper  temperature  and  the 
control  of  the  rate  of  flow  of  the  solution. 

Another  very  important  thing  is  the  maintenance 
of  drainage  from  infected  wounds.  In  order  to 
insure  the  perfection  of  drainage  the  wound  should 
be  loosely  packed  and  lightly  covered.  This  is 
important  because  otherwise  infecting  microbes 
multiply,  tissues  become  damaged  and  devitalized, 
sepsis  is  promptly  caused  and  rapidly  increases. 

The  injuries,  as  we  already  know,  are  of  every 
imaginable  sort.  Each  tissue  in  the  body — skin, 
fascia,  muscle  and  bone;  head,  trunk  and  extremities; 
vessels,  nerves  and  viscera,  all  are  invaded  by  the 
missiles  of  warfare.  The  developments  of  modern 
surgery  to  meet  these  dreadful  injuries  are  not  short 
of  marvelous  in  their  accomplishment,  and  the  share 
of  the  nurse  in  this  great  work  is  acknowledged  and 
appreciated. 

What  are  the  guiding  principles  in  the  treatment 
of  every  wound? 

1.  It  must  be  made  clean. 

2.  This  must  be  accomplished  with  thoroughness 
and  great  gentleness,  that  sensitive  tissues  be  not 
unnecessarily  disturbed  and  new  avenues  of  infection 
opened  up. 

3.  Once  clean,  the  wound  must  remain  so. 

In  these  conditions  the  satisfactory  exploration 


70  WAR  NURSING 

and  cleansing  can  hardly  be  made  without  anesthesia. 
Foreign  material  is  to  be  removed,  such  as  fragments 
of  missiles  and  of  bone,  bits  of  clothing,  skin,  dirt, 
etc.  Collections  of  debris,  such  as  damaged  tissue 
and  blood  clots,  are  acting  as  plugs  to  shut  in  dis- 
charges, making  cavities  not  entirely  air  tight — so 
that  aerobes  or  pus-forming  bacteria  are  still  at 
work,  but  forming  recesses  where  anerobes  also  find 
spaces  to  their  liking.  Therefore,  the  entire  area 
must  be  laid  open  and  the  invaders  dislodged. 

In  modern  hospitals,  especially  in  war  hospitals, 
the  motto  may  well  be  " Always  ready;'7  therefore 
preparations  are  assumed  to  be  sufficient  and  com- 
plete for  whatever  is  to  be  done,  and  space  is  not 
given  here  to  enumerating  the  "  list  of  things  needed, " 
(moreover,  the  nurse  who  needs  a  list  at  such  a  time 
will  not  be  able  to  fill  the  demands  of  the  situation) . 

These  will  include  a  multiplicity  of  instruments  in 
duplicate  (see  page  72) — gloves,  gowns,  etc.,  sterile 
dressings,  antiseptics,  outfits  for  nurse  and  assistants 
as  well  as  for  surgeon,  anesthetics,  hypodermic 
syringe  and  tablets,  infusion  apparatus,  etc.,  etc., 
always  ready  and  always  in  order,  with  an  abundance 
of  sponges,  drains,  and  gauze.  The  usual  prepara- 
tion of  the  patient — bathing,  sterilizing  of  surfaces, 
is  carried  out  in  all  cases.  The  complication  always 
to  be  apprehended  is  hemorrhage,  as  in  the  early 
cleansing  and  removal  of  foreign  matter  vessels 


THE  WOUNDED  MAN  71 

may  be  opened;  therefore,  it  is  important  that  instru- 
ments for  arresting  hemorrhage  and  all  appliances 
for  this  purpose  also  be  at  hand. 

If  the  patient  is  not  seen  very  soon  after  his  acci- 
dent, the  tissues  are  already  harboring  microbes 
which  may  be  beyond  the  reach  of  antiseptics  and 
for  this  reason  a  proceeding  will  follow  which  has 
been  well  developed  in  the  present  war,  namely, 
excision  of  wounds. 

This  is  made  necessary,  not  only  by  microbic  in- 
vasion, but  because  of  the  conditions  which  imme- 
diately surround  the  wound.  Only  when  extensive 
invasion  has  already  occurred,  with  much  engorge- 
ment and  infiltration  of  tissues  at  a  distance  beyond 
the  lesion,  is  the  measure  not  applicable,  and  even 
then  the  skin  and  superficial  structures  may  be 
removed  with  advantage.  When  seen  in  time,  all 
damaged  tissues  which  are  accessible — skin,  fascia, 
muscle  and  bone — may  be  gotten  rid  of  and  the 
process  of  healing  will  begin  promptly. 

The  object  of  excision  then,  is  by  removing  the 
infected  area  to  prevent  the  spread  of  infection  and 
facilitate  rapid  healing. 

The  tissues  surrounding  the  wound  caused  by  gun- 
fire are  more  or  less  in  a  state  of  local  shock  and 
quickly  become  devitalized.  The  stasis  of  the  vessels 
and  injuries  to  nerve  filaments  prevent  recovery,  and 
the  whole  condition  favors  the  multiplication  and 


72  WAR  NURSING 

action  of  the  invading  bacteria  carried  to  the  wounds 
by  missiles  and  foreign  material. 

The  irregularities  of  the  wound  surfaces  form 
pockets  and  recesses  making  it  very  difficult  to  per- 
fectly drain  the  cavities;  they  also  form  resting 
places  where  blood  clots  and  damaged  tissue  are 
retained.  To  correct  this  condition  the  removal  of 
the  entire  infected  area  is  the  ideal  method  of 
proceeding. 

Method,  as  described  by  Col.  Gray,  the  originator. 

The  wound  is  laid  open,  thoroughly  washed  with 
disinfectants  (iodine  in  a  10  per  cent,  alcoholic  solu- 
tion is  advised),  carefully  dried,  all  bleeding  stopped 
if  possible  (the  iodine  assists) ,  and  the  damaged  tis- 
sues are  boldly  removed.  The  surfaces  now  brought 
into  view  are  supposed  to  be  surgically  clean  and 
are  dealt  with  accordingly.  They  are  again  carefully 
dried  and  packed  very  lightly  with  sterile  gauze  for 
temporary  protection. 

Now  a  complete  change  is  made  of  all  instruments 
and  implements;  the  nurse  will  see  that  the  clean 
set  is  ready  to  replace  every  article  used,  as  the  wound 
is  now  aseptic  and  must  be  treated  as  such.  After 
suturing,  a  dressing  is  applied,  probably  something  like 
the  following  which  has  proved  highly  satisfactory: 

A  varnish  which  has  the  property  of  drying  rapidly 
is  painted  over  the  sutures  and  for  some  distance 
on  either  side.  When  dried,  this  will  be  covered  by 


THE   WOUNDED  MAN  73 

two  layers  of  gauze  extending  about  two  inches  be- 
yond all  parts  of  the  wound.  Smoothly  stretched 
over  the  varnished  sutures,  it  is  ready  for  a  thin  cov- 
ering of  wool  and  a  suitable  bandage-  This  dressing 
gives  support  to  the  wound  and  relieves  the  tension 
of  stitches.  Another  advantage  is  the  ease  of  in- 
spection gained  by  removing  all  but  the  deepest 
layer  of  gauze  without  disturbing  the  stitches  which 
are  plainly  seen  through  it  and  the  transparent 
varnish. 

All  wounds  are  looked  upon  as  infected  and  ex- 
perience has  taught  that  a  wise  precaution  is  the 
administration  of  tetanus  antitoxin  as  soon  as  prac- 
ticable after  the  patient  arrives,  since  the  tetanus 
bacillus  is  prevalent  in  the  battle-grounds  of  the 
present  war.  A  standing  order  to  this  effect  is 
sometimes  given  and  the  instruments  therefor  should 
be  at  hand,  ready  for  use. 

Bullet  wounds  are  often  but  slightly  infected,  and 
if  the  bullet  can  be  easily  extracted  the  wound  may 
be  covered  with  sterile  dressings  and  considered 
aseptic,  but,  with  this  exception,  practically  all 
wounds  are  infected  and  the  nurse  must  be  ready 
for  whatever  treatment  is  adopted. 


CHAPTER  VII 


MECHANICAL  APPLIANCES 

Extension  Apparatus. — The  application  of  "Buck's 
extension"  apparatus  is  or  should  be  familiar  to  every 
nurse,  who  will  have  occasion  to  apply  it  frequently 
in  caring  for  surgical  cases  in  military  hospitals. 
The  principle  involved  is,  that  by  drawing  injured 
surfaces  away  from  each  other  we  place  them  in  the 
best  position  for  repair;  not  that  they  actually  need 
to  be  separated,  but  they  should  be  protected  from 
the  pressure  which  muscle  contraction  causes  them 
to  exert  upon  each  other,  as  in  the  case  of  fractured 
bones,  and  again  in  the  case  of  inflamed  or  wounded 
joints.  To  the  part  below  the  injury  a  wide  strip 
of  adhesive  plaster  is  securely  applied  on  either  side, 
extending  well  below  the  extremity  of  the  limb.  To 
these  strips  a  weight  is  attached  by  means  of  a  cord 
and  pulley,  with  an  intervening  foot  piece,  which 
will  keep  the  part  at  rest.  Counter-extension  is 
secured  by  some  device  which  pulls  the  upper  frag- 
ment of  bone  in  the  opposite  direction.  For  ex- 
ample, when  a  lower  extremity  in  extension  is  ele- 
vated and  the  foot  of  the  bed  as  well,  the  weight  of 

74 


MECHANICAL  APPLIANCES  75 

the  body  inclining  toward  the  head  of  the  bed  fur- 
nishes a  means  of  counter-extension. 

The  use  of  extension  appliances  is  more  and  more 
depended  upon  for  securing  immobilization,  the 
splints  being  utilized  for  the  necessary  support  of 
the  damaged  structures,  and  in  some  instances  sup- 
plying a  point  of  attachment  for  extension  plasters. 

Splints. — The  primary  object  of  all  splints  is 
immobilization  and  support  of  the  wounded  part 
(usually  a  fractured  bone  or  joint)  to  prevent  dis- 
placement of  fragments  with  injury  to  the  soft  tis- 
sues, and  the  irritation  which  would  be  caused  by 
friction.  Therefore,  splints  are  made  of  unyielding 
material  as  wood  or  metal. 

NOTE. — Always,  in  all  fractures,  the  joint  above 
and  the  joint  below  must  be  immobilized. 

Simple  or  closed  fractures  where  only  the  bone  is 
injured,  can  be  enclosed  in  fixed  dressings  which 
need  not  often  be  disturbed,  but  in  war  surgery 
nearly  every  fracture  is  compound  and  many  are 
comminuted,  with  much  damage  of  muscle  and  fascia 
and  tearing  of  vessels  and  nerves,  conditions  which 
demand  frequent  attention;  therefore,  splints  are 
chosen  which  not  only  secure  fixation  but  give  access 
to  wounds  without  disturbing  the  relations  of  the 
bones  themselves  or  the  position  of  the  splint.  Also 
they  must  be  made  of  material  which  can  be  dis- 
infected. Wooden  fracture  boxes  or  frames,  or 


76  WAR  NURSING 

long  straight  splints  are  sometimes  used  in  necessity, 
but  the  choice  is  for  some  sort  of  skeleton  splint  or 
metal  framework,  strong  but  not  cumbersome, 
adapted  to  various  purposes  and  conditions. 

The  splints  now  in  use  are  so  devised  that  they 
provide  for  not  only  the  fixation  of  the  wounded  part 
but  a  fairly  comfortable  position  of  the  same,  when- 
ever the  nature  of  the  injury  will  allow.  Sometimes 
a  long  stiff  splint  like  the  old  fashioned  Listen,  must 
be  used,  in  which  case  the  nurse,  by  skill  in  arranging 
pillows  and  bedding,  cotton  padding,  etc.,  can 
alleviate  so  far  as  may  be,  the  inevitable  discom- 
fort accompanying  its  use,  as  for  instance,  needless 
pressure  on  one  special  part,  like  the  heel,  which 
may  be  remedied  by  a  soft  small  pad  of  cotton  in- 
serted under  the  ankle,  or  by  a  ring  in  which  the 
heel  rests,  without  changing  the  position  of  the  foot 
or  of  the  splint  itself.  Likewise  under  the  knee,  a 
compress  may  be  placed  which  will  give  the  patient 
a  sense  of  support  by  filling  the  hollow  of  the  popliteal 
space. 

In  the  following  pages  are  brief  descriptions  of  a 
few  splints  in  common  use  in  the  hospitals  of  the 
present  war.  Numberless  modifications  exist,  sug- 
gested by  the  necessities  of  special  cases. 

The  genius  of  the  surgeon  aided  by  the  cleverness 
of  artisans  in  orthopedic  appliances  (attached  to  the 
best  stationary  hospitals),  has  developed  a  variety 


MECHANICAL  APPLIANCES  77 

of  such  for  all  sorts  of  conditions;  it  may  be  added 
that  they  are  distinguished  by  a  multiplicity  of 
names  although  modeled  upon  simple  and  similar 
lines. 

The  Hodgen  splint,   the   Thomas  hip  and  knee 
splints,  the  Mclntyre,  and  others  of  similar  design 


FIG.  7. — Skeleton  splint  resembling  the  Hodgen  splint. 
(After  Hull.) 

are  most  frequently  used.  The  Hodgen,  for  frac- 
tures of  the  femur,  consists  of  parallel  rods  or  bars 
of  strong  metal  connected  at  either  extremity  and 
once  near  the  middle  by  cross  pieces  of  proper 
curve.  Strips  of  webbing  are  attached  to  the  side 
bars  and  support  the  limb  in  a  series  of  slings  as  it 
lies  upon  them.  Extension  is  applied  above  the 
knee;  slight  bending  of  the  frame  at  the  knee  allows 
both  thigh  and  leg  to  rest  more  comfortably  because 
it  prevents  some  of  the  strain  of  the  flexor  muscles 
at  the  back  of  the  limb  (see  Fig.  7). 

The  Mclntyre  splint  for  injuries  of  the  thigh  or  leg 


78  WAR  NURSING 

is  in  two  parts  composed  of  metal,  hinged  at  the  bend 
of  the  knee  and  provided  with  a  foot  piece.  It  is 
placed  behind  the  limb.  The  metal  pieces  are 
curved  to  form  a  gutter  in  which  the  limb  rests.  The 
position  of  the  thigh  depends  upon  the  angle  between 
the  two  parts  and  can  be  adjusted  by  means  of  sliding 
rods  which  control  the  joint.  This  is  adapted  for 


PIG.  8. — De  Puy's  double  inclined  plane  splint  constructed  and 
used  very  much  on  the  plan  of  the  Mclntyre  splint. 

support  and  comfort,  but  for  convenience  in  chang- 
ing dressings  it  would  have  to  be  modified  by 
sectioning  the  splint  (see  Fig.  8). 

The  Thomas  Hip  Splint.  This  consists  of  a  single 
flat  piece  or  stem  of  iron  which  is  placed  vertically 
at  the  back  of  the  patient,  being  moulded  to  fit 
the  curves  of  the  body.  At  the  upper  extremity  is  a 
metal  ring  large  enough  to  pass  around  the  chest  at 
the  level  of  the  axilla;  another  ring  encircles  the 
thigh  and  still  another  the  leg  just  above  the  ankle. 
Two  strong  straps  or  bands  attached  to  the  upper- 
most ring,  are  crossed  and  pass  over  the  shoulders 


MECHANICAL  APPLIANCES 


79 


like  suspenders  to  prevent  it  from  slipping  down. 
This  splint  immobilizes  both  hip  and  knee,  with 
the  pelvis  as  well.  With  an  elevated  shoe  on  the 


FIG.  9. — The  Thomas  knee  splint  applied  with  extension.  The 
cord  and  weight  are  attached  to  adhesive  plaster  strapping  not 
shown  in  the  cut.  (After  Hull.) 

sound  side,  the  patient  may  walk  about  with  crutches 
without  disturbing  the  injured  joint. 

The  Thomas  Knee  splint  (Fig.  9)  is  found  to  be 
indispensable,  as  it  can  be  varied  to  suit  special  cases 
and  in  different  sizes  may  be  used  for  thigh,  leg,  arm 


80  WAR  NURSING 

or  forearm.  It  consists  of  two  metal  rods,  connected 
above  by  a  ring  of  the  same  metal  well  padded  and 
covered  with  leather  or  other  appropriate  substance 
which  can  be  disinfected,  and  again  at  the  lower 
extremities  by  a  smaller  ring.  These  parallel  rods 
should  reach  from  shoulder  or  pelvis  to  points  several 
inches  below  the  hand  or  foot  as  the  .case  may  be. 
The  upper  ring  is  large  enough  to  slip  over  the  thigh 
in  its  whole  length  if  used  for  the  knee,  and  may  be 
fixed  obliquely  so  that  one  side  rests  close  to  the  pubic 
arch  and  the  other  beneath  the  crest  of  the  ilium. 
The  lateral  rods  are  connected  with  each  other  by 
slings  of  leather  or  several  pieces  of  metal  which  hang 
like  a  hammock  from  the  two  bars  to  support  the  leg 
and  thigh  from  beneath.  This  sling  being  in  sections, 
a  wound  of  any  given  part  may  be  made  accessible 
for  dressing.  Sometimes  strong  bandaging  is  used 
for  parts  of  the  sling,  which  still  more  easily  allow 
access  to  the  wound.  The  splint  is  kept  from  slip- 
ping down  by  a  strap  which  crosses  over  the  opposite 
shoulder.  By  elevating  the  lower  extremity  of  this 
double  splint  the  whole  limb  may  be  swung  in  a  long 
cradle.  If  extension  is  needed  the  usual  adhesive 
plaster  strips  are  applied  as  in  other  cases,  and  at- 
tached to  a  weight  by  continuations  of  bandaging  and 
a  cord  which  passes  through  the  foot  piece  or  lower 
end.  Counter-extension  may  be  secured  by  fastening 
the  bandages  directly  to  the  foot  piece. 


MECHANICAL  APPLIANCES  8 1 

The  advantages  of  this  splint  are  several: 

1.  A  wound  may  be  dressed  without  removing  it, 
the  sling  being  in  sections  so  that  any  part  may 
be  reached  without  disturbing  the  whole. 

2.  It  is  light  in  weight  and  in  a  smaller  size  may 
be  used  for  the  upper  extremity  also,  with  the  large 
ring  resting  in  the  axilla  and  over  the  shoulder. 


FIG.  10. — DePuy's  wire- netting  splint — light,  adjustable  and 
convenient. 

3.  It  may  be  made  to  fit  an  extremity  with  the 
joint  slightly  flexed  which  adds  greatly  to  the  com- 
fort of  the  patient. 

4.  With  it  wet  dressings  may  be  used  or  irrigation — 
continued  or  interrupted,  while    bedding  and  pa- 
tient are  kept  perfectly  dry. 

If  a  patient  is  brought  in  resting  securely  on  a 
frame,  with  both  lower  extremities  extended,  abducted 
and  motionless,  himself  lying  flat  and  in  apparent 
comfort,  the  abduction  splint  of  Major  Robert  Jones, 


82 


WAR  NURSING 


R.  A.  M.  C.  (of  Liverpool)  may  be  recognized.  This 
is  an  adaptation  of  a  double  Thomas  splint,  for  frac- 
tures of  the  hip  or  upper  part  of  the  femur,  by  means 
of  which  the  pelvis  and  both  limbs  are  immobilized 
and  the  injured  side  extended,  with  counter-exten- 


FIG.  ii. — "Balkan"  frame. 

sion  from  the  opposite  side  of  the  pelvis.  It  is  a  most 
ingenious  and  successful  adaptation  of  the  principles 
of  the  Thomas  splint  to  a  troublesome  condition. 
Upon  this  frame  the  patient  may  be  lifted  or  carried, 
with  safety  to  his  broken  bones. 

Frequently  there  is  complaint  of  skin  irritation  by 
pressure  of  the  pelvic  or  axillary  ring  of  the  Thomas 
splint;  the  nurse  is  not  allowed  to  move  the  ring  but 


MECHANICAL  APPLIANCES  83 

may  press  the  soft  tissues  down  and  draw  a  different 
portion  of  skin  under  it  from  time  to  time. 

By  means  of  the  Balkan  splint  very  ingenious  ar- 
rangements are  made  for  immobilization  of  extremi- 
ties in  different  positions.  A  simple  method  of 
construction  is  as  follows:  an  overhead  wooden 
frame  is  made  of  two  upright  pieces,  placed  at  the 
head  and  foot  of  the  bed  and  connected  by  a  strong 
bar.  A  more  elaborate  and  very  useful  frame  em- 
bodying the  same  features  is  now  supplied  by  the 
instrument  maker  (Fig.  n).  To  these,  pulleys  and 
cords  are  attached,  and  by  them  various  parts  or 
whole  extremities  may  be  suspended  in  slings,  or 
held  in  extension,  or  both,  as  required.  The  body  of 
the  patient  even,  may  be  lifted  by  slings.  The  great 
advantage  of  the  Balkan  splint  or  frame  is  that  limbs 
may  be  slung  and  extended  in  any  position  most 
desirable  for  the  union  of  fractured  bones  or  healing 
of  wounds.  It  may  be  used  for  the  suspension  of 
irrigation  flasks  also;  indeed  its  possibilities  are 
without  number. 

For  fractures  of  the  humerus  a  triangular  splint 
(p.  116)  made  of  three  strips  of  wood  or  other 
material,  is  applied  with  the  base  of  the  triangle  at 
the  side  of  the  chest,  while  the  arm  and  fore-arm  are 
supported  by  the  two  other  sides.  It  is  so  fastened 
to  the  chest  by  strips  of  bandaging  that  the  upper 
angle  just  reaches  the  axilla,  while  the  forearm  is 


84  WAR  NURSING 

flexed  and  the  elbow  rests  at  the  apex  of  the  triangle, 
with  the  arm  in  the  abducted  position. 

The  "aeroplane"  is  the  name  given  to  a  splint 
constructed  of  strong  wire  or  metal  rods  upon  similar 
principles.  It  is  attached  to  the  chest  of  the  patient 
by  means  of  broad  metal  plates,  curved  to  fit  the 


FIG.  12. — Leyva's  aeroplane  splint. 

body;  and  is  provided  with  devices  to  vary  the  posi- 
tion of  the  arm  or  forearm  while  affording  firm 
support,  and  it  may  be  adapted  to  the  securing  of 
extension. 

Plaster  Bandages  and  their  Application. 

It  may  fall  to  the  nurse  to  prepare  plaster  bandages 
and  apply  them.  No  new  principles  are  evolved  by 
recent  practice.  The  rules  are  few:  Keep  your  plas- 
ter dry  being  a  cardinal  one.  This  applies  to  the 
supply  of  plaster  itself  as  well  as  to  bandages,  and  is 
most  important.  It  must  be  kept  in  air-tight  and 
damp-proof  boxes,  sealed,  and  stored  in  a  dry  place. 


MECHANICAL  APPLIANCES  85 

The  bandages  most  frequently  used  are  five  yards 
long  and  from  three  to  four  inches  wide.  After 
rolling,  each  one  is  to  be  securely  wrapped  in  waxed 
paper  containing  some  loose  plaster,  and  a  number 
packed  in  tin  cans  which  are  sealed  with  adhesive 
plaster  and  kept  in  a  dry  warm  place.  As  an  extra 
precaution  each  bandage  may  be  wrapped  snugly  in 
old  muslin  in  addition  to  waxed  paper,  as  for  trans- 
port across  the  ocean. 

When  about  to  apply  a  plaster  dressing,  wash,  dry, 
and  powder  the  patient's  limb  or  the  part  to  be 
covered  and  bandage  it  with  flannel  or  flannellette. 
Have  ready  two  basins;  one  to  contain  the  salt  and 
water  (not  too  hot)  in  which  the  bandages  are  wetted — 
and  deep  enough  for  the  bandage  to  be  covered  with 
water  while  standing  on  end;  another  for  occasional 
dipping  of  the  hands  of  the  operator,  and  a  smaller 
dish  for  plaster  "cream,"  a  box  of  dry  plaster,  hot 
and  cold  water  in  pitchers,  towels,  protectors  for  the 
floor  and  patient,  and  a  knife.  Also  non-absorbent 
cotton  to  protect  from  pressure  upon  special  parts. 

When  all  is  ready,  open  the  box  of  bandages  and 
place  them  one  at  a  time  in  the  water  as  needed 
and  called  for.  Meanwhile,  mix  the  dry  plaster 
to  make  a  "cream"  and  place  it  where  the  doctor 
can  reach  it  easily,  for  reinforcing  and  "finishing 

The  limb  or  part  must  be  supported  exactly  in  the 


86  WAR  NURSING 

position  which  it  is  to  retain  after  the  plaster  is  set. 
(Someone  should  be  detailed  to  place  the  succession 
of  bandages  in  the  water  as  the  surgeon  indicates, 
as  of  course,  all  can  not  be  wetted  at  one  time.) 

NOTE. — If  the  bandages  are  soaked  in  water  too 
cool  the  patient  will  be  chilled;  if  in  water  too  hot, 
he  will  be  burned. 


FIG.  13. — Showing    a    method    of  using  plaster  of  Paris    for    a 
damaged  joint  having  a  wound  to  be  dressed.    (Modified  from  Hull.) 

It  is  of  special  importance  to  maintain  the  correct 
position  of  the  limb  during  the  entire  preceding,  in 
order  to  insure  the  drying  of  the  cast  in  just  the  right 
shape. 

In  the  exercise  of  the  ingenuity  which  has  been  so 
greatly. developed  by  the  necessities  of  the  present 
war,  plaster  of  Paris  dressings  or  casings  have  been 
adapted  to  a  great  variety  of  injuries  in  addition  to 
their  common  uses  for  simple  fractures. 


MECHANICAL  APPLIANCES  87 

For  example,  the  necessity  for  early  transportation 
of  the  man  with  severe  lesions  of  long  bones,  or  joints, 
has  led  to  the  extensive  use  of  interrupted  plaster 
casings,  whereby  the  injured  parts  are  fully  secured 
against  the  mechanically  harmful  effects  of  the 
journey  and  at  the  same  time  may  receive  the  care 
which  open  wounds  demand  (Fig.  13). 

The  portions  of  the  casing  above  and  below  the 
lesion  are  connected  by  unyielding  strips  of  metal, 
arched  over  the  wound  and  protecting  the  dressings 
perfectly,  as  well  as  guarding  against  pressure  upon 
the  sensitive  part. 

One  skilled  in  the  handling  of  plaster  will  find  a 
multitude  of  opportunities  for  its  use.  It  forms  the 
very  best  support  for  transportation,  and  by  means 
of  windows  over  the  wound,  necessary  dressings  may 
be  done. 

With  very  large  fractures  of  pelvic  bones  about  the 
hip,  or  for  other  joints  as  the  elbow  or  knee,  plaster 
can  be  used  above  and  below  the  wound  and  con- 
nected by  the  curved  metal  bands  referred  to,  which 
secure  the  desired  immovability  while  protecting 
the  wound  from  pressure  and  allowing  facilities  for 
redressing.  Many  cases  are  thus  transported  with 
safety,  to  reach  the  base  hospital  where  alone  the 
necessary  treatment  can  be  had  for  those  requiring 
care  during  a  long  period  of  time,  which  it  would 
otherwise  be  impossible  to  give. 


88  WAR  NURSING 

Many  special  applications  might  be  described; 
they  necessarily  vary  with  the  requirements  of 
different  patients,  but  the  indispensable  requisites 
for  success  in  their  use  may  be  repeated:  keep 
your  plaster  dry;  secure  the  maintenance  of  the 
proper  position  until  the  cast  is  hard,  then  it  will 
almost  take  care  of  itself. 

NOTE. — The  removal  of  the  cast  will  be  facilitated 
by  cutting  it  down  to  the  lower  layers  while  the  plaster 
is  still  soft.  If  you  have  time  to  consider  esthetics 
varnish  it  and  bind  with  adhesive  plaster. 


CHAPTER  VIII 

BATH    TREATMENT.      BURNS.      TETANUS. 
GANGRENE 

The  Bath  Treatment  in  Surgical  Work. — This, 
like  some  other  methods,  is  not  a  demonstration  of 
new  ideas,  but  an  adaptation  to  present  conditions. 

Various  containers  are  devised  which  allow  the 
immersion  of  a  limb  wholly  or  in  part — or  even 
the  greater  portion  of  the  body.  The  success  of  the 
treatment  will  depend  upon  continuous  immersion 
in  the  right  solution  at  the  right  temperature  and 
with  the  limb  in  the  right  position.  The  limb  or 
body  is  supported  by  strapping,  by  sheeting,  by 
netting  or  other  material  fastened  to  the  tub  or 
around  it,  to  keep  the  part  floating  in  the  water,  the 
temperature  of  which  (usually  100°  or  higher)  is 
maintained  at  the  proper  degree  by  various  devices; 
these  are  necessarily  under  the  control  of  the  nurse. 
Frequent  supervision  is  needed  and  the  position  of 
the  patient,  as  well  as  that  of  the  limb,  is  to  be  care- 
fully preserved. 

The  effect  of  hot  immersion  is  to  increase  the  cir- 
culation, thus  bringing  to  the  injured  tissues  the 
nutritive  principles  of  the  blood,  to  be  utilized  for 

89 


90  WAR  NURSING 

future  repair.  When  it  can  be  managed,  no  treat- 
ment is  better  for  large  septic  surfaces  or  for  in- 
fected burns.  Suitable  boxes  or  containers  of  some 
sort  should  be  obtained  almost  anywhere  for  an 
arm  or  for  a  leg. 

The  general  immersion  bath  is  sometimes  the  only 
comfortable  dressing  for  large  sluggish  superficial 
wounds.  The  securing  of  a  requisite  quantity  of 
sterile  water  may  be  a  problem  too  great,  but  at  least 
plain  boiled  water  can  be  had;  sometimes  it  will 
be  medicated  by  mild  antiseptics,  as  boric  acid  or 
(brief  immersion  in)  a  0.5  per  cent,  solution  of  picric 
acid.  A  very  great  advantage  obtained  by  the  use 
of  the  bath  is,  that  for  such  wounds  long  and  pain- 
ful dressings  are  avoided.  The  disadvantage  lies  in 
the  necessity  for  lifting  the  patient  from  the  tub 
from  time  to  time,  but  the  benefits  outweigh  the 
annoyances. 

BURNS 

The  use  of  liquid  fire  and  asphyxiating  gases  in 
the  European  war,  has  added  to  the  list  of  battle 
wounds.  Extensive  burns  involving  the  deep  layers 
of  skin  and  underlying  tissues  have  presented  prob- 
lems of  treatment  to  both  surgeon  and  nurse.  They 
have  been  exposed  to  infection  on  the  battlefield 
without  defense  or  prompt  treatment,  but  being 
superficial  wounds  they  present  mostly  the  effects 


BURNS  QI 

of  pus-forming  microbes  only,  which,  the  patients' 
strength  being  sufficient, — can  be  overcome  by  suit- 
able treatment. 

The  time-honored  method  of  dealing  with  burns  is 
by  the  application  of  bland  and  soothing  remedies  to 
exclude  the  air  The  experiences  in  the  present  war 
have  led  to  the  perfecting  of  such  methods  with  the 
addition  of  antisepsis.  Paraffin  is  the  basis  of  vari- 
ous mixtures  which  have  been  used  to  make  an  air- 
tight covering  without  irritation.  By  many  it  has 
been  determined  that  a  pure  article  of  paraffin  of 
suitable  texture  and  consistency  will  answer  the 
purpose  without  the  addition  of  various  medica- 
ments included  in  the  published  formulae;  most  of 
these  contain  small  quantities  of  rosin,  wax,  and 
petrolatum.  Ambrine,  the  most  widely  and  very 
successfully  used,  contains  oil  of  amber  with  other 
substances  in  combination. 

The  method  of  applying  is  as  follows:  the  wound  is 
disinfected  (usually  with  hydrogen  peroxide  or  ether) , 
cleansed  and  very  carefully  dried.  Then  a  thin  coat- 
ing of  paraffin  at  melting  temperature  is  applied 
either  by  spray  or  with  a  soft  brush  (the  spray  is 
difficult  to  manage,  many  use  the  brush).  This  is 
covered  with  a  thin  layer  of  cotton  and  another  coat- 
ing of  paraffin  is  added.  Cotton  and  light  bandaging 
are  used  to  keep  the  dressing  in  place.  As  the  sur- 
face has  been  made  aseptic  the  dressing  may  be  so 


92  WAR  NURSING 

applied  as  to  prevent  both  the  entrance  of  air  and 
the  escape  of  fluids;  although  by  many  this  is  not 
considered  an  advantage,  the  process  of  healing  is 
probably  encouraged  (see  Fig.  14). 

NOTE. — Should  the  application  of  the  paraffin  be 
very  painful  a  preparatory  layer  of  sterile  petrolatum 
is  advised  and  frequently  used  to  precede  the  paraffin. 


iii 


FIG.  14. — Pierce's  ambrine  atomizer.  In  this  the  difficulty  of 
preserving  the  proper  temperature  is  overcome  and  the  fine  spray 
is  delivered  satisfactorily. 

Other  methods  of  treatment  of  burns  have  been 
practically  superseded  by  this  one  in  many  war  hos- 
pitals. They  are  not  especially  new  and  are  not 
described  here,  but  the  use  of  the  continuous  irriga- 
tion bath  of  normal  saline  or  medicated  solutions 
should  not  be  disregarded,  and  for  very  extensive 
areas  of  injury  it  is  one  of  the  best  of  procedures.  It 
meets  the  important  indications  to  alleviate  pain  and 
keep  the  sensitive  part  at  rest,  with  a  minimum  of 


TETANUS  93 

disturbance  for  re-dressing,  the  importance  of  which 
will  be  understood  by  recalling  the  effect  upon  the 
brain  and  other  vital  organs  of  long  continued  pain- 
ful sensations  (see  p.  27).  Meanwhile  the  patient's 
strength  is  to  be  conserved  by  nutritious  and  care- 
fully digested  food. 

TETANUS 

Of  the  three  anaerobes  which  are  common  in  war 
wounds  the  bacillus  of  tetanus  is  most  dreaded.  The 
frequency  of  tetanus  infection  in  the  early  days  of  the 
war  caused  many  deaths. 

A  description  of  the  disease  is  hardly  necessary 
here  but  it  is  well  to  mention  characteristics  and 
symptoms  which  the  nurse  will  wish  to  understand 
and  watch  for.  The  period  of  incubation  is  of  very 
uncertain  length  but  it  is  usually  long.  The  deadly 
work  of  the  bacillus  tetani  goes  on  very  slowly  as  a 
rule,  showing  no  symptoms  whatever  meanwhile, 
until  the  mischief  is  extensive.  The  toxin  of  this 
bacillus  is  formed  at  once  in  the  wound  and  attacks 
the  injured  nerves  promptly;  by  them,  not  by  the  cir- 
culation, it  proceeds  to  the  motor  cells  of  the  central 
nervous  system,  affecting  first  those  in  the  spinal  cord 
which  belong  to  nerves  in  the  wound ;  later  it  goes  on 
up  to  the  brain,  including  the  pons  and  medulla, 
where  are  found  the  vital  parts  of  the  nervous 
system. 


94  WAR  NURSING 

Because  it  secures  so  firm  a  footing  before  the  in- 
fection is  recognized,  the  main  hope  for  the  patient 
lies  in  attacking  it  at  the  earliest  possible  moment  and 
this  can  not  be  too  early.  No  opportunity  is  given 
for  identification  of  the  bacillus;  the  time  required  for 
laboratory  work  is  time  lost  for  the  patient  and  the 
enemy  must  be  convicted  upon  circumstantial  evi- 
dence. Many  methods  of  treatment  have  been 
tried  but  few  have  proved  equal  to  that  of  antitoxic 
serum  and  none  have  superseded  it,  either  for  immuni- 
zation or  as  a  remedy  for  the  fully  developed  disease. 
Therefore,  tetanus  antitoxin  will  be  administered  to 
thousands  of  men,  in  immunizing  doses,  every  day 
while  the  war  lasts  and  the  nurse's  armamentarium 
for  the  proceeding  must  be  kept  as  complete  as 
possible. 

NOTE. — The  practice  is  now  established  of  admin- 
istering an  immunizing  dose  to  every  wounded  man 
as  soon  as  it  may  be  done  upon  his  arrival  at  the  hos- 
pital. By  many  surgeons  this  is  repeated  before 
any  operation  which  he  may  need  a  few  days  later. 
And  because  of  the  insidious  nature  of  the  toxin  and 
the  short  period  of  immunity,  another  dose  is  often 
given  although  no  signs  of  infection  may  be  visible. 
Again  it  may  be  repeated  when  the  man  is  sent  away 
to  convalesce,  and  even  after  he  arrives  at  a  conva- 
lescent hospital.  All  these  will  be  prescribed,  with 
the  doses,  either  for  special  individual  cases  or  as 
routine  measures. 


TETANUS  95 

Early  detection  may  enable  the  surgeon  to  insti- 
tute treatment  before  it  is  too  late.  What  are  the 
warning  symptoms?  Just  a  drawing  of  the  muscles 
of  the  limb  that  is  wounded;  sensitiveness  to  sound 
or  to  a  slight  draft  is  suspicious — never  overlook 
these;  slight  difficulty  in  swallowing  must  be  recog- 
nized at  once,  and  as  to  stiffness  of  the  muscles  of 
the  jaw  or  the  least  tendency  to  spasmodic  action 
of  these,  everyone  knows  the  meaning  of  that ;  be  on 
the  watch  for  these  symptoms  in  every  wounded  man. 

In  addition  to  the  antitoxin  other  remedies  are 
used  for  palliative  effects;  magnesium  sulphate  among 
them,  in  a  25  per  cent,  solution  injected  into 
the  muscles  four  times  daily,  minimizes  the  severity 
of  convulsions  and  thus  conserves  the  patient's 
strength  while  the  more  radical  effect  of  the  serum 
is  becoming  established. 

Chloretone  also  has  been  used  with  favorable  re- 
sults. Several  other  remedies  have  been  proposed 
but  none  of  these  alone  is  to  be  trusted;  the  main 
dependence  is  upon  the  serum  and  we  may  almost 
say  that  with  the  early  and  frequent  use  of  this 
remedy  the  others  will  not  be  required. 

NOTE. — It  goes  without  saying  that  thorough 
cleansing  of  wounds  is,  if  possible,  still  more  imper- 
ative than  ever  where  tetanus  infection  has  taken 
place,  as  if  any  tetanus  bacilli  remain,  fresh  supplies 
of  toxin  will  be  produced  continually,  and  even  with 


WAR  NURSING 


ARTERIES 
minium  VEINS 


PIG.  15. — Sho\ving  the  main  arterial  supply  to  the  human  body 
and  the  veins  which  return  the  blood  to  the  heart.  The  sources  of 
severe  hemorrhage  may  be  understood  from  this  figure. 


BLOOD-VESSEL  INJURIES.  97 

the  aid  of  serum  the  tissues  will  not  furnish  anti- 
bodies indefinitely. 

INJURIES  OF  BLOOD  VESSELS 

The  importance  of  this  subject  is  due  to  the  danger 
of  hemorrhage  for  which  the  nurse  must  be  constantly 
on  the  alert.  Bullets,  fragments  of  shell,  or  shrapnel, 
may  be  lodged  in  the  vessel  walls  without  quite  pene- 
trating them,  therefore  constant  vigilance  is  impera- 
tive as  severe  hemorrhage  is  almost  inevitable  when 
the  weakened  vessel  gives  way.  Or,  the  ends  of 
severed  vessels  which  have  been  closed  by  nature's 
method,  that  is,  the  formation  of  a  clot,  may  be  re- 
opened by  mechanical  injury  in  the  course  of  dealing 
with  the  wound  which  contains  them,  and  again 
serious  hemorrhage  follows.  This  is  particularly 
liable  to  occur  in  septic  cases. 

As  a  temporary  measure  a  wound  may  be  packed 
with  gauze  which  has  been  soaked  in  a  strong  salt 
solution  or  an  antiseptic,  and  a  firm  bandage  applied. 
In  most  cases  this  is  better  than  the  use  of  a  tourni- 
quet. If  a  tourniquet  must  be  used  a  pad  or  some 
hard  object  must  be  applied  over  the  main  artery 
which  supplies  the  vessels  in  the  wound,  as  a  bandage 
or  any  other  constricting  material  which  exerts  equal 
pressure  upon  the  entire  circumference  of  the  limb, 
is  capable  of  doing  as  much  harm  as  good — first,  by 
preventing  return  of  blood  through  the  large  veins 


9  WAR  NURSING 

and  thus  bandaging  it  into  the  limb;  second,  owing 
to  the  possibility  of  gangrene  if  the  tourniquet  is 
tight  enough  to  shut  off  all  circulation.  (This  possi- 
bility must  be  kept  in  mind  when  dealing  especially 
with  the  common  femoral  and  the  popliteal  arteries). 
Third,  it  is  probable  that  the  pressure  thus  exerted 
upon  the  nerves  is  in  part  responsible  for  the  occur- 
rence of  gangrene,  because  it  cuts  off  the  vasomotor 
supply  to  the  great  vessel  walls. 

When  a  wounded  artery  bleeds  into  the  tissues 
surrounding  it,  the  swelling  is  called  a  hematoma.  If 
the  tissues  are  very  firm  as  in  Hunter's  canal,  a  well 
defined  cavity  filled  with  blood  will  be  formed,  called 
a  false  aneurysm.  The  natural  cure  for  this  is  by 
formation  of  a  clot,  but  if  the  injury  is  too  extensive 
the  only  relief  is  by  operation. 

Space  is  lacking  for  mention  of  various  other  conditions 
caused  by  injuries  of  arteries  and  veins  and  their  treatment. 

After  ligation  of  arteries,  which  is  done  when  hem- 
orrhage is  otherwise  uncontrollable,  it  is  necessary 
to  keep  the  part  well  supported  and  the  patient 
absolutely  at  rest,  that  the  circulation  be  not  hurried 
in  any  way.  The  heart's  action  is  not  to  be  stimu- 
lated. 

Keep  the  extremity  of  the  injured  part  sufficiently 
wrapped  or  covered  to  preserve  the  normal  tempera- 
ture. 


BLOOD-VESSEL  INJURIES  99 

In  all  injuries  of  blood  vessels  the  effect  of  sepsis 
is  unfavorable,  as  it  promotes  secondary  hemorrhage, 
consequently  the  care  of  an  infected  wound  must  be 
carried  out  most  scrupulously  according  to  orders 
and  with  antiseptic  precautions. 

The  repair  of  vessel  walls  by  the  use  of  grafts  of 
deep  fascia  is  now  constantly  practiced,  especially 
for  injured  cranial  sinuses. 

The  latter  is  a  very  beautiful  proceeding,  calling 
for  surgical  skill  of  a  high  order.  A  piece  of  fascia 
lata  of  the  proper  size  is  placed  upon  a  slightly 
larger  piece  of  delicate  rubber  tissue,  called  jaconet. 
The  sheath  of  the  vessel  having  been  carefully  re- 
moved from  the  wounded  area,  the  fascia  is  applied 
over  the  wound  by  a  delicate  manipulation  which 
coaxes  it  to  remain  in  place  by  holding  it  gently  but 
firmly  against  the  vessel  wall  for  a  minute  or  two; 
when  the  rubber  is  taken  off,  the  fascia  remains 
adherent. 

Vessels  are  often  repaired  by  suturing  as  they  pos- 
sess good  powers  of  healing. 

The  only  uncertain  factor  in  the  proceeding  is  the 
possible  danger  of  infection  during  the  operation  or 
from  suture  material.  Frequently  such  sutures  are 
covered  by  a  fascial  flap  like  that  already  described. 

The  skill  exercised  by  modern  surgery  has  made  it 
possible  to  repair  wounds  of  vessels  which  formerly 
were  inevitably  fatal.  It  remains  to  be  shown  that 


100  WAR  NURSING 

the  skill  of  the  modern  trained  nurse  will  conduct 
the  case  to  a  successful  termination.  Nothing  can 
replace  the  responsibilities  which  she  must  assume 
in  such  cases.  The  patient  should  be  absolutely 
protected  from  emotional  or  other  unnecessary  dis- 
turbance; he  must  be  able  to  rest  in  a  comfortable 
position;  his  wants  are  to  be  met  by  prompt  and 
skilful  attendance*;  his  food  should  be  suitable,  and 
secondary  hemorrhage  is  never  to  occur  unexpectedly. 
Secondary  hemorrhage  may  be  anticipated  of  tenest 
after  ligation  of  vessels  in  any  part  of  the  body  under 
the  following  conditions: 

1.  Where  a  branch  of  good  size  has  been  severed 
or  ligated  close  to  the  main  trunk. 

2.  In  a  septic  wound  where  tissues  are  necrotic  and 
sloughing  and  the  walls  of  the  vessels  themselves  are 
probably  softened. 

3.  Where  primary  hemorrhage  has  occurred  and, 
as  in  many  vessels  of  the  skull,  it  was  necessary  to 
adopt  some  form  of  plugging  or  stopping,  because 
the  vessel  was  not  accessible. 

4.  Wherever  the  vessel  is  surrounded  by  damaged 
tissue  as  in  the  lung. 

5.  In  compound  fractures — where  spicules  of  bone 
are  lodged  in  or  near  a  vessel  or  where  a  tablet  of 
eupad  or  of  salt  has  been  allowed  to  come  in  contact 
with  a  vessel  in  the  depth  of  a  wound. 

Repetition  will  not  emphasize  the  importance  of 


GANGRENE  IOI 

watchfulness  wherever  the  possibility  of  hemorrhage 
exists,  nor  enforce  the  instructions  already  given 
in  regard  to  the  measures  for  meeting  the  accident 
should  it  happen.  All  have  been  described  and 
will  undoubtedly  be  instituted  with  promptness  and 
successfully  carried  out. 

NOTE. — It  is  a  remarkable  fact  that  complete 
division  of  the  third  part  of  the  axillary  artery  and 
lower  part  of  the  femoral,  the  tibial,  radial  and  ulnar, 
has  been  seen  with  no  serious  hemorrhage,  in  the 
present  war. 

GANGRENE 

Gangrene  is  denned  as  "the  death  of  a  part  of  the 
body  from  failure  in  nutrition." 

Dry  gangrene  is  not  common  in  war,  because 
although  it  may  follow  injury  to  an  artery  in  battle, 
it  usually  follows  disturbances  of  circulation  due  to 
either  vaso-motor  spasm  or  diseased  vessel  walls. 

The  fingers  and  toes  are  the  parts  oftenest  affected. 
An  early  and  continuous  symptom  is  severe  pain. 
The  skin  is  at  first  white  and  bloodless,  later  it  be- 
comes red  and  later  still  black.  A  white  line  appears 
to  mark  off  the  black  portion,  which  does  not  recover. 
When  this  is  positive,  amputation  is  done.  The  foot 
or  hand  should  be  kept  warm  with  the  hope  of  secur- 
ing a  return  of  circulation  if  possible  and  the  patient 
should  rest  quietly  in  bed. 


102  WAR  NURSING 

Moist  gangrene  is  the  more  common  form  and  is 
seen  after  injuries.  The  characteristics  are  swelling, 
oedema,  and  a  white  surface  soon  becoming  mottled 
and  presenting  blebs  which  are  filled  with  bloody 
serum.  After  bursting  they  leave  a  raw  surface  with 
foul  odor.  The  soft  tissues  of  the  limb  are  soon 
invaded  and  the  process  is  a  rapidly  advancing  one; 
the  life  of  the  patient  is  saved  only  by  amputation 
well  above  the  diseased  portion. 

Gas  Gangrene. — The  majority  of  cases  of  gangrene 
among  the  soldiers  is  due  to  anerobic  infection  and 
takes  the  form  known  as  gas  gangrene.  In  former 
times  this  serious  disease  amounted  to  a  scourge 
but  owing  to  the  better  understanding  of  the  cause 
and  the  development  of  recent  methods  of  war 
surgery,  the  cases  now  are  comparatively  few, 
although  they  are  more  numerous  than  could  occur 
in  civil  life.  The  infecting  agent  is  called  the 
bacillus  perfringens,  or  the  bacillus  aerogenes  capsulatus 
or  the  bacillus  Welchii.  (The  bacillus  of  malignant 
oedema  causes  a  similar  condition.) 

If  the  microbes  are  lodged  in  a  small  but  deep 
wound  these  bacteria  multiply  rapidly  with  the  forma- 
tion of  gas  and  great  destruction  of  tissue.  How 
much  more  serious  then,  are  the  large  wounds  with 
ragged  tissues,  numerous  recesses  and  pockets,  and 
the  whole  obstructed  by  fragments  of  broken  down 
and  dying  or  dead  muscles  and  other  tissues,  so  that 


GANGRENE  103 

air  does  not  penetrate  to  the  depths;  there  the  gas 
bacilli  can  work  under  circumstances  most  favorable 
to  their  activities.  If  the  wound  is  seen  in  time  and 
the  devitalized  tissues  are  excised,  recovery  may  be 
expected,  but  probably  it  will  not  be  considered  safe 
to  dispense  with  antiseptics  or  hypertonic  saline 
remedies.  These  measures,  with  excision  and  all 
of  the  nourishing  food  which  can  be  provided,  may 
save  the  man. 

The  course  of  the  disease  varies  somewhat,  being 
at  first  a  local  condition;  bubbles  of  gas  appear  in 
the  discharges  from  the  wound  and  gas  may  be  felt 
in  the  tissues  of  the  immediate  neighborhood,  but 
these  symptoms  may  be  brought  under  control  by 
prompt  discovery  and  treatment  by  free  incisions, 
and  thorough  disinfection  and  drainage.  By  the 
use  of  these  measures  the  process  may  be  restricted 
to  a  limited  area.  Certain  muscles  will  be  lost,  and 
with  them  the  corresponding  motions,  leaving  the 
patient  crippled  to  that  extent;  but  beyond  this, 
recovery  will  follow. 

A  more  serious  and  fatal  form  is  the  di/use  or 
rapidly  spreading  process.  The  skin  is  discolored, 
the  limb  is  extremely  swollen  and  oedema tous,  gas 
penetrates  the  cellular  tissues  and  advances  rapidly, 
so  pressing  upon  the  muscles  as  to  render  them  useless 
and  obstructing  vessels  and  nerves;  the  pulse  is 
small  and  rapid,  the  extremities  are  cold,  vomiting 


104  WAR  NURSING 

and  hiccough  may  occur.  The  patient  is  profoundly 
toxic  but  he  may  not  feel  very  ill;  at  first  he  is  hardly 
able  to  realize  the  gravity  of  his  situation.  If  im- 
provement can  not  be  secured  by  thorough  exposure 
of  all  pockets  and  excision,  a  fatal  ending  soon 
comes — the  gas  spreading  rapidly  upward  to  the 
abdomen,  chest,  and  then  the  neck,  causing  distress- 
ing pressure  symptoms  and  death. 

At  another  time  the  whole  limb  is  involved  sud- 
denly, beginning  within  a  few  days  of  the  initial 
injury.  A  wound  which  is  doing  fairly  well  at  night 
may  reveal  a  condition  of  gangrene — swollen,  tense, 
and 'discolored  in  the  morning;  the  patient,  already  in 
collapse,  succumbs  before  the  gas  itself  has  spread 
far  enough  to  cause  death.  This  form  is  called 
gangrene  en  masse. 

NOTE. — The  toxin  of  these  infections  weakens  the 
heart  especially;  the  patient  becomes  pulseless  and 
circulation  fails  in  advance  of  other  functions. 

White  gangrene  presents  a  white  and  shining  skin, 
moist,  cold,  and  pitting  on  pressure.  The  patient's 
condition  is  dangerous  from  the  first  and  symptoms 
of  collapse  followed  by  death  often  occur  within 
12  hours.  If  the  patient  lives  longer  than  this  his 
skin  becomes  spotted  with  black  color  and  the  dis- 
charge will  be  exceedingly  fetid  but  with  very  little 
pus. 


GANGRENE  105 

Early  amputation  gives  the  man  his  only  hope;  the 
delay  of  a  few  hours  may  cost  the  patient's  life. 

In  all  of  these  forms  of  gangrene,  conserve  the 
patient's  strength  in  all  possible  ways  and  try  to 
build  it  up  by  food  and  stimulants.  Protect  the 
surfaces  from  cold,  try  to  keep  the  extremities  warm 
—this  is  very  important. 

A  peculiar  board-like  hardness  followed  by  rigidity 
of  muscles  in  a  definite  area,  has  been  reported  as  a 
fore-runner  of  gangrene.  It  has  been  observed  in 
the  leg,  below  a  wound. 

Injury  of  a  deep  vessel  is  suggested  by  the  condi- 
tion which  has  been  invariably  followed  by  gan- 
grene of  grave  nature. 

It  would  be  well  for  the  nurse  to  watch  for  this 
sign  and  report  it  if  discovered;  an  opportunity 
might  thus  be  afforded  for  early  operation  and  the 
saving  of  life. 

NOTE. — As  the  result  of  a  number  of  bacteriologic 
tests  anerobic  bacteria  were  found  not  only  on  all 
of  the  uniforms  of  a  number  of  Belgian  soldiers  who 
had  come  directly  from  the  trenches,  but  in  the 
meshes  of  all  the  examined  samples  of  the  new  cloth 
from  which  the  uniforms  were  made !  How  could 
any  escape  infection? 

IMPORTANT  NOTE. — Experiments  are  reported 
which  go  to  prove  that  an  antitoxic  serum  has 
been  made  which  is  "protective  and  curative  against 
gas  bacillus  infection  in  pigeons." 


CHAPTER  IX 
BONE  INJURIES 

The  graduate  nurse  will  have  had  experience  in 
the  care  of  fractures  during  her  course  of  training. 
By  far  the  greater  number  will  have  been  simple 
or  closed  fractures  in  which  the  injury  is  simply  a 
broken  bone.  Briefly,  the  treatment  and  nursing 
must  be  such  as  to  secure  a  position  of  comfort  as 
far  as  possible  and  to  insure  the  immobility  or  fixa- 
tion of  the  part  by  proper  support  during  repair. 

Review  the  process  of  repair  and  union. 

First. — The  mechanical  irritation  results  in  freer 
blood  supply;  then  a  certain  amount  of  animal  sub- 
stance like  cartilage  is  thrown  out  about  the  frac- 
ture forming  a  callus  which  joins  the  upper  and 
lower  fragments  together.  When  this  is  hardened 
by  deposits  of  mineral  substance  the  callus  becomes 
bone  and  in  time  the  bone  is  as  strong  as  ever. 
The  object  to  be  secured  in  treating  the  fracture  is 
that  the  bone  shall  be  so  supported  while  the  callus 
is  soft  that  its  former  shape  will  be  retained. 

In  all  fracture  cases  a  certain  routine  is  observed: 

First. — Extension,  to  prevent  friction  or  irritation 
between  the  broken  surfaces;  not  that  they  must 

106 


BONE  INJURIES  107 

be  actually  pulled  apart,  but  the  muscles  which  are 
attached  to  the  bone  need  to  be  steadied  and  invol- 
untary contractions  have  to  be  discouraged.  To 
accomplish  this,  the  limb  must  be  not  only  extended, 
but  comfortably  supported.  The  extension  should 
secure  the  continuous  effect  of  a  definite  and  unchang- 
ing weight;  intermittent  extension  causes  rather  than 
overcomes  muscle  action. 

Second. — Immobilization  (or  fixation)  to  keep  the 
fragments  in  apposition  during  the  process  of  re- 
pair. This  is  accomplished  by  means  of  splints 
which  are  bandaged  firmly  to  the  limb. 

These  measures  taken,  the  care  is  left  to  the  nurse 
who  will  see  that  the  bandages  which  hold  the  splints 
in  place  are  not  too  tight,  thus  interfering  with 
circulation  and  causing  painful  pressure  upon  nerves ; 
or  on  the  other  hand  that  they  are  not  too  loose,  thus 
failing  to  keep  the  splints  in  place,  and  if  necessary 
she  will  report  concerning  them. 

It  is  important  that  in  all  handling  of  the  patient 
such  as  lifting  or  turning  and  changing  of  bedding 
or  clothing,  the  fractured  limb  be  supported  by  a 
sufficient  number  of  assistants  to  avoid  disturbing 
it  in  any  manner.  In  the  case  of  large  bones  this 
will  include  special  support  on  both  sides  of  the 
fracture  until  new  bone  is  formed. 

All  these  things  become  a  matter  of  routine  for 
which  untrained  assistants  may  well  be  instructed 


IO8  WAR  NURSING 

to  take  responsibility  while  the  nurse  in  charge  is 
necessarily  occupied  with  patients  whose  conditions 
are  more  acute,  the  care  of  wljich  could  hardly  be 
entrusted  to  inexperienced  hands. 

Such  will  be  the  care  of  compound  or  open  frac- 
tures. These  present  a  wound  to  be  dealt  with  also. 
In  civil  life  the  wounds  may  be  sterilized,  the  limb 
extended,  the  bones  immobilized  and  drainage 
established,  when  it  is  expected  that  satisfactory 
union  and  healing  will  follow.  Their  care  requires 
that,  more  than  ever,  vigilance  be  exercised  in 
handling  the  injured  limb  or  moving  the  patient, 
since  there  is  danger  of  not  only  disturbing  the 
fragments  of  the  bones  but  of  injuring  the  soft  tissues 
about  them. 

Always  such  wounds  received  in  battle  are  infected 
and  not  only  are  they  open  fractures  but  usually 
the  bone  is  splintered  or  broken  into  several  pieces 
or  crushed,  and  another  danger  arises — that  of 
injury  to  blood-vessels  and  nerves  by  fragments  of 
bones. 

Consider  the  situation  at  the  depth  of  the  wound. 
This  may  have  been  caused  by  a  missile  of  explosive 
character,  seriously  damaging  the  muscles  and  other 
soft  tissues,  and  nerves  and  blood-vessels  as  well, 
creating  a  condition  favorable  to  the  development 
of  bacteria  carried  in  by  fragments  of  missiles,  of 
clothing,  or  dirt,  and  causing  rapid  development  of 


BONE  INJURIES  IOQ 

sepsis.  Any  injury  due  to  careless  handling  might 
easily  cause  the  spread  of  infection  by  further 
mutilation  of  tissues  already  damaged,  causing 
severe  sepsis,  perhaps  secondary  hemorrhage  and 
gas  gangrene.  Could  the  patient  be  seen  in  time  it 
might  be  possible  to  sterilize  such  a  wound,  but 
facilities  for  this  do  not  exist  at  the  field  dressing 
stations,  and  the  patient  must  be  sent  on  to  a  clear- 
ing station  for  his  first  thorough  treatment. 

Therefore,  when  a  patient  arrives  with  limbs  in 
splints,  the  nurse  will  think  at  once  to  observe  if  a 
wound  exists.  She  will  look  to  see  in  that  case  that 
drainage  is  not  obstructed;  she  will  instruct  her  as- 
sistants how  to  support  the  patient  and  the  limb  dur- 
ing necessary  changes  of  position,  placing  in  bed, 
removal  of  clothing,  etc.,  remembering  that  always 
the  wounded  limb  is  to  be  uncovered  last. 

FRACTURES  OF  THE  LOWER  EXTREMITY 

Fractures  of  the  pelvis  usually  involve  the  hip, 
and  all  are  immobilized  together.  Wounds  when 
existing,  are  large  and  ragged;  muscles  are  mutilated 
and  furnish  bleeding  surfaces;  vessels  are  numerous 
and  of  good  size  and  one  is  reminded  that  hemorrhage 
may  occur.  These  conditions  have  to  be  treated  as 
such  are  dealt  with  elsewhere,  that  is,  by  excision  if 
practicable  and  sometimes,  closure;  but  more  often 


110  WAR  NURSING 

they  are  left  open  for  irrigation  and  drainage  or  the 
dressing  favored  by  the  surgeon,  being  too  badly 
damaged  to  permit  the  complete  excision  which 
would  make  closure  safe. 

Immobilization  includes  the  trunk  up  to  the 
shoulder  and  the  extremity  down  to  the  knee,  as  only 
so  can  all  of  the  muscles  concerned  be  brought  under 
control.  For  this  the  Jones  Abduction  splint  (see 
pp.  8 1  and  82)  or  something  like  it  is  applicable,  or  well 
applied  plaster  of  Paris. 

NOTE. — It  is  necessary  to  fix  the  entire  pelvis  when 
either  side  is  injured,  for  since  it  is  composed  of  bones 
united  by  immovable  joints,  any  motion  of  one  side 
inevitably  disturbs  the  other. 

Here  again  the  nursing  insures  perfection  of  drain- 
age, the  care  of  the  bed  and  dressings,  the  pro- 
curing of  as  much  nourishing  food  as  can  be  obtained, 
with  success  in  persuading  the  patient  to  take  it. 

Compound  Fracture  of  the  Femur. — In  the  major- 
ity of  cases,  prepare  for  immediate  operation,  as  the 
conditions  are  already  desperate,  microbes  having 
invaded  the  tissues  about  the  wound,  with  gangrene 
often  present.  Retained  foreign  bodies  must  be 
searched  for,  concealed  bleeding  discovered,  damaged 
tissue  removed;  and  there  is  special  danger  of  shock 
as  well  as  hemorrhage. 

NOTE. — Severe  shock  is  very  common  in  the  hand- 


BONE  INJURIES  III 

ling  of  compound  fractures  of  the  femur.  Be  pre- 
pared then  to  keep  the  patient  warm,  to  administer 
saline  solutions,  etc. 

These,  like  other  cases,  will  require  extension,  fixa- 
tion and  drainage,  which  must  be  carefully  watched. 


Femoral  nerve 
Femoral  artery 
Femoral  vein 


Deep  branch 


FIG.   1 6. — Structures  in  Scarpa's  triangle;  portion  of  sartorius 
removed.     These  vessels  may  be  injured  in  fracture  of  the  femur. 

It  is  important  to  keep  an  accurate  record  of  symp- 
toms and  to  sustain  the  patient's  strength  by  food 
and  such  stimulants  as  are  ordered.  The  patient 


112  WAR  NURSING 

will  already  be  septic  and  his  strength  must  be 
maintained  in  every  possible  way. 

Many  cases  will  require  amputation  and  most  of 
these  operations  will  be  performed  by  what  is  called 
the  open  method,  that  is,  no  attempt  will  be  made  to 
close  the  surfaces  of  the  stump,  as  the  injured  bone 
and  the  injured  tissues  surrounding  it  are  par- 
ticularly liable  to  the  effects  of  microbic  invasion. 
They  may  be  already  infected  and  to  close  the  sur- 
faces from  the  air  is  to  encourage  the  development 
of  anaerobic  bacteria.  The  closure  of  the  wound 
by  Nature,  after  amputation,  is  encouraged  and 
secured  by  a  plan  of  extension  of  the  soft  tissues  which 
draws  them  down  gradually,  so  that  finally  the  end 
of  the  bone  is  covered  during  the  process  of  heal- 
ing. The  after  treatment  of  compound  fractures 
requires  that  the  wounds  shall  be  accessible  for  the 
constant  application  of  antiseptics  or  saline  or  other 
solutions.  Many  splints  have  been  adapted  to  these 
cases  whereby  drainage  is  not  obstructed  and  the 
wound  can  be  frequently  dressed,  while  the  limb 
is  supported  in  the  proper  position  (see  pp.  77-79). 

The  Knee  Joint. — This  is  such  a  large  joint  and  so 
complicated,  that  injuries  are  proportionately  serious. 
It  is  a  hard-working  joint  also  and  exposed  to  vio- 
lence by  reason  of  its  location  in  the  body,  therefore 
accidents  are  bound  to  happen  to  it.  By  reason  of 
the  extent  of  synovial  membrane,  inflammation  and 
infection  are  greatly  dreaded  even  when  no  wound 


BONE  INJURIES 


exists.  Still  more  serious,  therefore,  is  the  condition 
of  the  knee  joint  which  has  received  a  battle  wound, 
perhaps  with  a  bullet  or  fragment  of  shell  lodged  in 
one  of  the  articular  bones  or  lying  in  a  pocket  of 


FIG.  17. — The  Thomas  knee  splint  applied  with  extension. 
The  cord  and  weight  are  attached  to  adhesive  plaster  strapping 
not  shown  in  the  cut.  (After  Hull.) 

the  joint.  The  danger  of  sepsis,  involving  a  long 
and  painful  experience,  is  to  be  warded  off  if  possible, 
and  here  also,  by  thorough  exploration  and  excision, 
the  best  promise  of  recovery  is  given  to  the  patient. 


114  WAR  NURSING 

When  a  positively  clear  tract  has  been  created  in 
this  way,  the  wound  is  sutured  and  the  various  struc- 
tures composing  the  joint  are  trusted  to  Mother 
Nature  who  so  often  justifies  the  confidence  reposed 
in  her  powers  of  healing. 

For  extension  and  fixation  the  Thomas  Knee 
Splint  or  one  somewhat  like  the  illustration  (Fig. 
1 8),  is  used;  it  will  make  the  patient  comfortable 
and  the  nurse  will  do  the  rest. 

Fractures  of  the  leg  are  common  in  war  time  and 
are  usually  compound.  In  fact,  the  simple  fracture 
of  any  bone  is  more  often  a  civil  than  a  war  injury. 

Extension  is  secured  in  the  usual  way  and  immo- 
bilization by  some  form  of  skeleton  splint  which  allows 
irrigation  and  whatever  dressing  is  ordered.  The 
leg  may  be  swung  from  a  Balkan  splint  or  frame 
and  supported  in  a  Thomas. 

These  fractures,  unless  they  involve  the  ankle,  are 
not  difficult  to  care  for,  if  the-always-to-be-observed 
rules  are  to  be  kept  in  mind — the  limb  is  to  be  motion- 
less, the  bandages  are  to  be  neither  too  tight  nor  too 
loose  (as  evidenced  on  the  one  hand  by  swollen  toes 
or  on  the  other  by  movable  splints  and  pain),  and 
the  extension  must  act  steadily  and  continuously. 

Ankle  injuries,  if  extensive,  are  not  so  easily  dis- 
posed of.  It  is  difficult  to  apply  an  extension  appara- 
tus satisfactorily,  although  there  are  ways  of  doing 
so,  as  by  a  sling,  including  the  heel  and  instep,  but 


BONE  INJURIES 

this  is  not  always  possible.  Crushed  feet  just  have 
to  lie  still  in  their  dressings  and  hope  that  antisepsis 
and  care  will  help  them  over  their  hard  road. 

Fractures  of  the  Upper  Extremity. — For  im- 
mobilizing the  humerus  or  the  bones  of  the  forearm 
a  small  Thomas  splint  has  been  used  with  the 
large  ring  fitted  over  the  shoulder  and  extension 
at  the  elbow  or  wrist,  as  may  be  desired.  (See  In- 
juries of  the  Shoulder,  p.  116.)  For  compound 


A 


PIG.  1 8. — Robert  Jones'  leg  splint,  modification  of  Thomas'. 

•fracture  of  the  bones  of  the  forearm  the  lath  treat- 
ment is  available  in  the  early  stages.  Where  much 
inflammation  exists  this  serves  an  excellent  purpose; 
later  the  triangular  splint  seen  in  the  illustration, 
the  " aeroplane,"  or  the  Thomas  splint  already  re- 
ferred to,  can  be  used  (see  p.  116).  By  ingenious 
management,  with  this  splint  fractures  of  the 
humerus,  injuries  of  the  elbow  and  fractures  of  the 
forearm — all  in  one  extremity — may  be  immobilized, 
extended,  and  supported,  so  that  the  patient  can 
walk  about.  Always  in  the  use  of  a  Thomas  splint 
judgment  and  ingenuity  must  be  exercised  in  saving 
the  skin  from  the  effects  of  pressure  by  the  ring. 


n6 


WAR  NURSING 


Little  pads  of  cotton  or  linen  inserted  under  the  ring 
may  be  moved  from  place  to  place,  or  the  skin 
itself  may  be  moved  by  gently  pressing  under  the 


FIG.    19. — Triangular   splint.  FIG.  20. — Robert  Jones'  hu- 

The   base  A  is   applied  to  the       merus  extension  splint  (modified 
side  of  the  chest;  the  angle  C       Thomas'), 
fits  the  flexed  elbow.     The  fore- 
arm rests  upon  the  side  D.   The 
splint  is  held  in  position  by  ad- 
hesive straps  or  bandaging. 

ring  and  pulling  it,  so  that  pressure  shall  come  over 
a  new  area. 

Compound  fractures  of  the  wrist  and  hand  are 
also  well  treated  in  the  bath,  the  temperature  of  the 
water  being  first  simply  warm  and  then  gradually 
raised  to  a  degree  as  hot  as  can  be  borne  without 


BONE  INJURIES  117 

burning,  thus  increasing  the  blood  supply  to  the 
part  and  assisting  it  to  overcome  sepsis. 

It  is  hardly  practicable  to  apply  special  splints 
to  fractures  involving  many  bones  of  the  hand. 
Therefore,  the  bath  and  the  saline  solution  are  more 
than  ever  valuable.  Contraction  of  the  fingers  in 
the  flexed  position  is  apt  to  follow  this  injury  and 
to  prevent  this,  various  appliances  have  been 
devised,  as  dorsal  extension  by  pieces  of  rubber  tub- 
ing attached  to  the  fingers  and  to  a  circle  of  light 
metal  like  aluminum  fixed  to  an  arm  splint.  This 
arrangement  permits  the  exercise  of  the  fingers  by 
voluntary  contraction  of  flexor  muscles  without 
the  bad  effect  of  over-action.  The  adjusting  and 
regulating  of  the  pieces  of  tubing  will  naturally 
be  a  part  of  the  nursing  care. 

INJURED  JOINTS 

Much  that  is  said  of  the  care  of  fractures  applies 
to  injured  joints,  with  the  addition  of  some  special 
measures,  as  for  instance,  aspiration,  to  relieve  the 
tension  caused  by  effusion  of  fluid  into  the  cavity  of 
an  inflamed  joint  which  is  not  open  and  is  presum- 
ably aseptic.  For  this,  it  is  advised  to  have  some 
antiseptic  fluid  at  hand  with  which  to  fill  the  needle 
before  insertion,  that  no  possibility  of  entrance  of 
air  through  the  needle  into  the  joint  will  exist  (a 


I.I  8  WAR  NURSING 

mixture  of  iodoform  and  ether  or  alcohol  is  often 
used). 

When  the  patient  has  reached  the  nurse  he  will 
already  have  had  some  treatment  but  as  in  com- 
pound fractures,  radical  measures  can  hardly  be 
undertaken  in  the  field  dressing  stations;  bandaging, 
splinting,  and  immobilization  as  well  as  possible  are 
there  done  to  prepare  the  man  for  transportation,  and 
he  is  then  sent  on. 

Immobilization  is  important  for  two  reasons,  not 
only  as  in  fractures  to  keep  the  bones  in  proper 
position  (not  apposition),  but  because  friction  within 
the  joint  cavity  increases  any  inflammation  of  the 
serous  membranes  already  existing,  tends  to  en- 
courage sepsis,  and  delays  healing. 

The  same  care  is  required  upon  the  reception  of 
the  patient  as  is  already  described  for  other  cases. 
In  preparing  for  operation,  which  is  often  inevitable, 
the  usual  routine  is  observed,  including  provision  for 
irrigation,  which  is  frequently  necessary. 

Where  the  articular  ends  of  the  bones  are  injured, 
special  effort  is  made  to  render  them  aseptic  if  possible, 
because  of  the  danger  of  free  absorption  in  the  cancel- 
lous  tissue.  Such  surfaces  are  extremely  painful  and 
if  the  joint  cavity  is  packed,  irrigation  will  be  ordered 
before  the  daily  change  of  packing  in  order  to  make 
the  removal  as  easy  as  possible.  Should  the  bone 
be  injured  in  the  neighborhood  of  the  medullary 
canal,  amputation  will  probably  be  done. 


BONE  INJURIES 

In  injuries  of  the  hip  joint  (see  p.  122)  the  pelvis  as 
well  as  the  femur  has  to  be  immobilized  to  secure  per- 
fect rest  for  the  joint  surfaces  and  this  is  often  accom- 


Tendon  of  biceps 
muscle 


Capsule 


FIG.  21. — Hip-joint.     (Morris.) 

plished  by  the  use  of  plaster  of  Paris  around  the  pel- 
vis, interrupted  by  some  such  device  as  is  seen  in  the 
illustration  (Fig.  21),  to  prevent  pressure  upon  the 
sensitive  parts  or  the  occlusion  of  drainage.  The 


120  WAR  NURSING 

long  Thomas  splint  from  the  shoulder  to  the  foot  may 
be  used,  or  one  of  the  modifications  described  on 
p.  78  whereby  the  splint  immobilizes  both  hips  aad 
knees  and  supports  the  whole  body. 


18      19 


10  11 

FIG.  22. — Muscles  of  anterior  aspect  of  thorax  and  shoulder. 
Note  the  large  muscles  attached  to.  the  upper  portion  of  the 
humerus.  Others  are  quite  as  important  on  the  posterior  aspect. 
These  would  prevent  union  of  fragments  if  the  head  were  crushed 
or  severed  from  the  shaft. 

Injury  to  the  shoulder  joint.  With  extensive 
damage  to  the  head  of  the  humerus  excision  will  be 
performed,  as  the  bone  can  not  be  so  treated  as  to  heal 
in  the  proper  shape.  Septic  tissues  can  then  be 
removed  and  the  wound  cavity  treated  either  with 
antiseptics,  or  saline  irrigation,  or  hypertonic  saline 
by  the  use  of  salt  sacs.  Recall  the  important  struc- 
tures around  the  shoulder  joint  to  be  avoided  or 


BONE  INJURIES 


121 


treated.  The  axillary  artery  and  vein  with  their 
branches,  the  brachial  plexus  of  nerves  with  its 
branches;  also  the  large  synovial  cavity  of  the  joint 
itself;  the  pouches  of  the  synovial  membrane  which 
extend  under  tendons  and  along  the  bicipital  groove 


Axillary  artery 


Lateral  cord 


Pectoral 
muc-cle 


FIG.  23. — Axillary  space.  Axilla  laid  open  by  division  of  anterior 
wall.  These  structures  may  be  injured  in  fracture  of  the  humerus 
and  of  the  shoulder. 

are  all  to  be  drained  and  perhaps  continuous  irriga- 
tion will  be  instituted.  The  slender  drains  stiffened 
with  wire  are  found  useful  in  these  cases.  The  tri- 
angular splint  commonly  used  is  mentioned  on  p. 

83. 


122  WAR  NURSING 

For  wounds  of  the  elbow  joint  similar  treatment  is 
carried  out;  removal  of  damaged  bone  and  other 
structures  including  all  septic  matter,  followed  by 
irrigation  and  drainage.  The  saline  bath  is  here 
practicable.  Skeleton  splints  of  aluminum  bands 
with  transverse  pieces  curved  to  fit  the  arm  and  fore- 
arm allow  free  access  to  the  joint  for  dressing.  Ex- 
tension may  be  made  by  the  use  of  a  modified 
Thomas  splint  and  irrigation  still  continued.  These 
furnish  good  work  for  the  nurse  in  keeping  the  splint 
undisturbed,  the  irrigations  administered,  and  the 
patient  comfortable,  with  the  skin  free  from  irrita- 
tion (see  Fig.  20). 

Wounds  of  the  wrist  and  ankle  joints  are  treated 
like  those  already  described;  and  in  both  the  saline 
bath  may  be  utilized.  In  all  joint  affections,  a 
knowledge  of  the  anatomy  of  the  parts  involved  will 
not  only  add  interest  to  the  work  of  nursing  but 
will  render  it  more  efficient. 

A  brief  review  follows  of  the  gross  anatomy  and 
relations  of  parts  of  the  principal  joints,  with  illus- 
trations, as  an  aid  to  understanding  the  easiest 
position  in  which  they  may  be  placed  without  undue 
tension  of  the  muscles  and  ligaments  about  them. 
The  application  of  the  principles  involved  will  be 
greatly  facilitated  by  the  possession  of  the  faculty  of 
putting  "one's  self  in  another's  place." 

Injuries  of  the  hip  joint  present  serious  complica- 


BONE  INJURIES  123 

tions,  involving  as  they  do  important  vessels  and 
nerves,  and  muscles  of  unusual  size  and  strength. 
Fortunately,  the  capsule  and  other  ligaments  are 
so  attached  that  they  are  not  subjected  to  strain  in 
the  supine  position.  Only  an  extreme  range  of  mo- 
tion makes  any  of  the  ligaments  tense.  The  same  is 
true  of  the  muscles.  The  only  position  which  puts 
any  of  the  muscles  on  the  stretch  is  extreme  abduc- 
tion, which  is  most  unlikely  to  be  assumed.  A  semi- 
flexed  position  is,  however,  most  comfortable  as  in 
the  case  of  the  other  joints.  Injuries  of  the  shoulder 
almost  always  mean  crushing  or  breaking  the  upper 
end  of  the  humerus.  Recall  the  number  of  strong 
muscles  attached  to  this  portion  of  bone  and  realize 
how  impossible  it  is  to  ketp  it  in  position  when  frac- 
tured. The  head  is  useless,  therefore  it  will  be  re- 
moved and  the  arm  put  up  in  an  "aeroplane"  or 
a  triangular  splint  to  fix  it  when  healed,  in  a  strongly 
abducted  position;  the  man  can  then  have  excellent 
use  of  the  arm  proper.  Recall  the  fact  that  the 
arm  is  swung  from  the  scapula  and  the  scapula  from 
the  spinal  column  and  the  side  of  the  thorax.  The 
scapula  glides  freely  forward  and  back,  or  upward 
and  downward  and  the  arm  moves  with  it,  while  the 
flexed  position  of  the  elbow  joint  will  permit  a  good 
range  of  motion  for  arm  and  hand. 

The  Knee  Joint. — So  much  of  weight-bearing  de- 
volves upon  this  joint  that  loose  ligaments  can  not 


124 


WAR  NURSING 


be    allowed.     Here    also    semi-flexion    relaxes    the 
greater  number.     If  the  lee:  is  extended  upon  the 


PIG.  24. — Popliteal  space.  (Holden.)  Observe  the  tendons  be- 
hind the  knee  joint — their  muscles  will  be  put  on  the  stretch  in  ex- 
treme extension,  a,  Biceps;  6,  peroneal  nerve;  c.  plantaris, ;  d,  lateral 
head  of  gastrocnemius;  e,  semitendinosus;  /,  semimembranosus; 
g,  gracilis;  h,  sartorius;  i,  medial  head  of  gastrocnemius. 

knee  to  the  fullest  degree  a  strain  falls  upon  the  pos- 
terior ligament,  and  also  upon  the  tendons  of  the 
flexor  muscles  behind  the  joint — the  biceps,  semi- 


ADVANTAGES   OF   JOINT   FLEXION  125 

tendinosus  and  semi-membraneous,  and  the  popliteus 
as  well. 

NOTES. — Wherever  very  large  vessels  and  nerves 
cross  a  joint,  they  are  placed  on  the  flexor  aspect, 
where  tension  most  seldom  exists.  The  semi- 
flexed  position  is  that  of  repose  and  in  the  upper 
extremity  it  is  that  of  activity  also,  very  much  of  the 
time. 

Observe  by  testing,  that  if  in  any  case  it  is  neces- 
sary to  place  the  hand  in  extreme  extension,  a  flexion 
at  the  elbow  joint  will  make  this  act  less  difficult. 

Nothing  can  make  extreme  extension  of  the  foot 
endurable.  The  same  is  true  of  the  elbow,  unless 
the  forearm  is  in  pronation.  Here  it  is  the  biceps 
which  is  put  on  the  stretch  in  extension,  and  the 
round  pronator  in  supination;  in  pronation,  nothing 
is  badly  stretched. 


CHAPTER  X 
INJURIES  OF  THE  HEAD 

Practically  all  injuries  of  the  skull  involve  the 
brain  and  one  or  more  cranial  nerves.  The  cases 
are  always  grave  and  of  great  interest.  The  wounds 
vary  in  character  from  a  single  puncture  or  one  which 
appears  to  include  only  the  scalp,  to  those  with  much 
damage  of  all  structures  involved.  Serious  symp- 
toms with  seemingly  trivial  external  wounds,  are 
found  later  to  depend  upon  deep  injury  of  bone  with 
pressure  upon  the  brain,  and  require  from  the  first, 
intelligent  observation  and  the  careful  handling 
which  is  demanded  in  the  care  of  all  cranial  injuries. 

It  has  been  found  that  a  man  whose  injuries  do 
not  actually  forbid  transportation,  will  do  better 
if  operation  be  deferred  until  he  reaches  the  sta- 
tionary or  base  hospital,  than  when  it  is  done  at  once 
and  the  necessity  for  transporting  him  too  soon 
afterward  can  not  be  avoided.  The  post-operative 
condition  is  a  critical  one  and  after-treatment  is  of 
vital  importance  to  recovery,  therefore  the  greater 
number  of  head  injuries  will  fall  to  the  care  of  the 
graduate  nurse. 

The  man  will  probably  be  X-rayed  as  soon  as 
126 


INJURIES  OF  THE  HEAD  127 

possible  after  arrival  and  then  placed  in  the  care  of 
the  nurse. 

A  good  rule  for  general  guidance  is  that  a  patient 
with  an  injury  of  the  head  (especially  if  hemorrhage 
is  imminent  or  if  the  brain  itself  is  injured),  should 
be  placed  in  a  half -sitting  position,  and  here  is  one 
of  the  instances  where  the  nurse  who  is  a  master  of 
pillows  will  score  highest.  (Remember  the  tendency 
to  slip  down  in  the  bed,  and  provide  pillows  or  rolls 
of  some  sort  to  prevent  this — pillows  under  the  knees 
strapped  or  tied  to  the  head  of  the  bed,  and  firm 
rolls  at  the  feet.  It  is  supposed  that  Fowler  beds 
are  not  always  available.) 

For  satisfactory  inspection  the  scalp  is  always 
shaved;  and  as  a  routine  measure  a  laxative  will 
probably  be  ordered  at  once,  and  perhaps  frequent 
doses  of  urotropin  with  the  hope  of  protecting  the 
cerebrospinal  fluid  from  infection. 

(NOTE. — In  connection' with  the  latter  remedy*  the 
possibility  of  bladder  irritation  is  to  be  remembered.) 

It  is  probable  that  many  such  cases  will  be  moved 
on  for  observation  and  diagnosis  or  treatment  later, 
but  it  would  be  well  for  the  nurse  to  understand 
symptoms  of  intra-cranial  hemorrhage  or  other  sus- 
pected conditions,  that  she  may  promptly  report 
them  and  thus  assist  the  surgeon  in  his  disposition 
of  the  patient. 


128  WAR  NURSING 

The  man  may  have  only  a  headache,  and  yet  there 
may  be  a  depressed  fracture  of  the  skull  and 
even  lodgment  of  a  fragment  of  bone  in  the  brain 
substance. 

Intracranial  hemorrhage  causes  pressure  symptoms 
which  vary  with  the  location  of  the  injury  and  are 
very  like  those  of  bone  compression.  Among  the 
earliest  are  headache  slight  or  intense,  drowsiness, 
mental  dullness,  giddiness  and  perhaps  vomiting;  ir- 
regularity of  pupils  (the  one  on  the  injured  side  being 
widely  opened)  and  slow  pulse. 

Any  one  or  more  of  these  should  fix  the  attention  of 
the  nurse.  A  pulse  still  slower,  with  rising  tempera- 
ture, flushing  conjunctives,  conjugate  deviation  of 
head  and  eyes  and  disturbance  of  vision,  with  decided 
loss  of  muscular  power  in  any  part  of  the  body,  indi- 
cate advancing  trouble  and  complete  paralysis  soon 
follows. 

There  is  no  established  order  for  the  appearance  of 
the  symptoms.  Paralysis  may  be  noticed  first,  but 
it  is  possible  (or  probable)  that  less  conspicuous 
signs  might  have  been  discovered  had  they  not  been 
overlooked. 

The  prompt  recognition  of  the  necessity  for 
operation  will  secure  such  gratifying  results  in  the 
quick  relief  of  symptoms  from  compression  or  hem- 
orrhage, that  the  nurse  will  be  more  than  satisfied 
with  her  share  of  the  treatment.  A  cranial  opera- 


INJURIES  OF  THE  HEAD  I2Q 

tion  always  means  excision  of  the  wound  and  tre- 
phining, and  the  nurse  can  not  too  soon  learn  to 
assemble  the  instruments  and  appliances  for  this 
proceeding  and  those  which  follow  it.  Methods  for 
the  control  of  hemorrhage  are  well  established,  but 
there  is  often  much  loss  of  blood  and  saline  infusion 
or  transfusion  may  be  necessary.  Be  prepared 
therefore  for  both.  The  apparently  bold  handling 
of  brain  tissue  may  excite  wonder,  but  if  bold,  it  is  no 
less  gentle  and  accurate.  If  damaged  brain  tissue  is 
found  it  will  be  removed,  because  it  easily  becomes 
septic  and  at  best  is  only  a  foreign  body  after  it  has 
ceased  to  be  normal.  The  wound  is  undoubtedly 
contaminated  and  without  early  operation  sepsis  is 
sure  to  occur. 

The  results  of  surgery  of  the  head  and  brain  are 
brilliant  in  the  war  hospital  as  elsewhere  and  even 
more  spectacular;  a  patient  with  such  serious  symp- 
toms as  paralysis,  loss  of  sensation,  aphasia  and 
epileptiform  attacks,  soon  presents  striking  changes 
for  the  better  and  every  promise  of  recovery,  after 
appropriate  operation  upon  the  skull  and  brain. 

It  is  impossible  to  describe  in  detail  the  numerous 
injuries  and  the  great  number  of  operations  devised 
for  their  relief.  But  mention  may  be  made  of  some 
matters  of  special  interest  in  the  conducting  of  brain 
surgery  in  a  military  hospital. 

First. — Brain  tissue  is  treated  like  any  other  tissue. 


130  WAR  NURSING 

That  infection  has  already  taken  place  is  the  rule, 
and  that  possibility  is  never  forgotten  even  while  signs 
are  lacking.  Wounds  are  excised,  foreign  bodies  and 
devitalized  portions  removed;  if  necessary,  drainage 
is  established.  Rubber  tubes,  metal  tubes,  silver  wire 
loops,  capillary  drains,  salt  sacs,  gauze,  all  are  used 
(the  latter  not  often,  as  the  soft  brain  tissue  becomes 
entangled  in  the  meshes). 

The  track  of  a  bullet  may  be  explored  as  in  other 
parts  of  the  body,  and  (if  pus  is  discovered)  a  drain 
introduced.  If  this  is  done  very  soon  after  the 
injury  is  received  further  effects  of  sepsis  may  be 
avoided. 

Control  of  hemorrhage  by  patches  of  temporal  or 
occipito-frontal  muscles,  repair  of  wounded  sinuses 
by  fascial  flap  or  pieces  of  fascia  lata  (cut  large — it 
shrinks),  the  washing  out  of  wound  tracks  and,  still 
more  wonderful — rapid  recovery.  Great  delicacy  of 
manipulation  makes  these  things  possible,  aided  by 
expert  X-ray  work  and  an  accurate  knowledge  of 
cerebral  localization. 

"Axiom. — For  head  operations  to  be  successful  the 
incisions  must  heal  before  the  hair  grows."  (Major 
Hull— " Surgery  in  War.") 

Add  to  the  above  the  operations  for  those  most 
dreadful  of  war  wounds  which  cause  mutilations  of 
the  face.  The  great  destruction  of  tissue  renders 
them  peculiarly  distressing  to  the  feelings  of  the 


INJURIES  OF  THE  HEAD  .131 

patient,  as  well  as  difficult  of  repair.  Time  and  per- 
sistent effort  added  to  great  surgical  skill  have 
accomplished  remarkable  things  for  the  sufferers 
from  these  injuries.  Plastic  surgery  has  here 
achieved  signal  triumphs;  noses,  cheeks,  and  eye- 
lids have  all  been  supplied  and  invention  has  pro- 
vided ways  by  which  the  patient  may  be  fed  while 
repairs  are  going  on.  The  Dental  units  have  manu- 
factured jaws  and  have  almost  persuaded  teeth  to 
grow  in  them.  Fig.  25  illustrates  a  useful  splint. 


FIG.  25. — Dorrance's  intermaxillary  splint. 

Danger  of  post-operative  hemorrhage  is  due  to  the 
size  and  great  number  of  severed  arteries  and  in  the 
early  stage  of  recovery  it  is  momentarily  appre- 
hended. 

Further  results  of  injuries  of  the  head  include  those 
of  the  cranial  nerves,  with  resulting  paralysis  or 
pain,  or  loss  of  sensation,  in  accordance  with  their 
location  (see  Fig.  26). 

A  wound  or  blow  received  at  the  side  of  the  head 
and  behind  the  ear  causes  loss  of  hearing,  or  if  above 
and  in  front  of  the  ear,  loss  of  the  power  of  articula- 
tion. At  the  back  of  the  head  a  severe  injury  would 


132 


WAR  NTOSING 


be  followed  by  disturbances  of  vision,  the  visual 
centers  having  suffered.     The  parts  involved  may 


be  seen  in  the  illustration  and  the  effects  of  their 
injuries  are  readily  inferred. 


INJURIES  OF  THE  HEAD  133 

At  the  side  of  the  face  loss  of  sensation  and  paraly- 
sis show  that  the  fifth  and  seventh  nerves  are  injured. 

Fractures  of  the  base  of  the  skull  are  accompanied 
by  hemorrhage  and  pressure  symptoms;  the  escaping 
blood  may  appear  at  the  external  ear,  or  by  the  nose 
or  mouth,  according  to  the  location  of  the  injury. 
These  are  not  always  operative  cases  in  the  usual 
acceptance  of  the  term;  possibly  decompression 
may  be  done  for  the  immediate  effect  when  an  in- 
crease of  intra-cranial  tension  is  evident. 

What  share  has  the  nurse  in  all  this?  To  her  is 
entrusted  the  securing  of  the  final  successful  results 
of  these  wonderful  operations,  by  protection  of  the 
patient  from  outside  disturbance  and  from  himself, 
that  he  may  be  content  to  rest  without  exertion  and 
forget  for  a  time  his  injuries  and  forebodings;  by 
scrupulous  care  of  drainage  and  dressings,  and  by  the 
detection  of  any  change  of  symptoms  and  recognition 
of  their  importance.  No  one  else  can  accomplish 
these  things  and  they  are  indispensable.  The  ad- 
ministration of  suitable  food  is  also  of  the  very  first 
importance.  It  must  be  nutritious  and  easily  diges- 
tible and  given  in  moderate  quantities  at  regular 
intervals. 

CAUTION. — Never  leave  the  patient  in  the  hands 
of  an  uninstructed  assistant;  attacks  of  excitement  or 
of  sudden  delirium  may  occur. 


134  WAR  NURSING 

Never  Leave  any  Patient  Without  Instructing  Your 
Substitute. 

Shell  Shock  or  Air  Concussion. — The  sudden  rari- 
fication  of  the  atmosphere  produced  by  a  passing 
shell  is  thought  to  cause  intimate  changes  in  the 
nerve  tissues  and  perhaps  gas  emboli  in  the  blood. 
The  immediate  effect  of  the  air  set  in  motion  by  the 
rapidly  moving  shell,  may  be  to  hurl  the  man  to  the 
ground  and  thus  produce  concussion  of  the  brain, 
perhaps  with  hemorrhage  in  brain  and  cord;  poi- 
sonous gases  from  the  shell,  or  sudden  emotion  or 
fright  all  leave  their  mark,  showing  later  as  mental 
confusion,  great  depression,  accelerated  pulse,  eye 
and  ear  affections,  paralysis  and  wasting  of  muscles; 
all  these  may  develop  and  still  no  external  wound  be 
discovered  as  the  cause.  Frequently  the  man  is 
possessed  by  hallucinations  and  inability  to  exercise 
self  control.  The  condition  in  these  cases  has  been 
classed  by  a  Russian  writer  as  "air  trauma tism  of 
brain  and  cord." 

The  symptoms  are  all  more  difficult  to  deal  with 
than  those  caused  by  actual  wounds.  The  rules  for 
the  care  of  individual  cases  can-  not  be  classified; 
all  must  be  dea,lt  with  kindly  and  patiently  as 
nervous  cases.  Rest,  if  possible  in  quarters  removed 
beyond  the  sound  of  firing,  and  security  from  depress- 
ing influences  are  essential  to  recovery. 

It  has  been  suggested  that  the  institution  of  pro- 


INJURIES   OF  THE  HEAD  135 

phylactic  measures  in  the  way  of  preparing  the  sol- 
dier's mind  for  what  is  before  him,  might  result  in  a 
diminution  of  the  number  of  such  conditions  of  the 
nervous  system,  since  it  is  probably  true  that  appre- 
hension and  terror  have  much  to  do  with  the  com- 
plete breakdown  of  the  man's  resistance.  He  may 
be  seeing  himself  a  hopeless  and  helpless  invalid. 
It  might  be  pointed  out  to  him  beforehand  that  such 
need  not  necessarily  be  the  case,  that  the  majority 
do  recover  from  such  accidents;  he  then  would,  if 
one  of  the  hysterically  liable,  recover  more  promptly — 
especially  with  intelligent  care. 

Many  times  a  man  is  brought  in  from  the  firing 
line  in  a  state  of  unconsciousness  when  he  was  per- 
fectly well  a  few  minutes  before,  the  explosion  of  a 
shell  near  by  having  produced  this  condition  without 
any  external  sign  of  physical  injury.  The  symptom 
is  due  to  compression,  rather  than  to  shock  as  the 
word  is  usually  applied,  and  may  last  a  long  time — 
perhaps  for  several  hours.  One  method  to  be  applied 
consistently  for  his  restoration  is  artificial  respira- 
tion, long  continued — not  abandoned  for  4,  5,  or  6 
hours,  since  "it  is  better  to  treat  a  dead  man  as 
though  he  were  alive,  than  to  treat  a  live  man  as 
though  he  were  dead." 

The  effects  of  these  accidents  are  always  grave  and 
recovery  long  deferred;  both  mental  and  physical 
powers  return  but  slowly  and  sometimes  the  nervous 
system  does  not  regain  its  balance. 


136  WAR  NURSING 

For  cases  of  long  protracted  unconsciousness,  when  it  is 
impossible  to  detect  by  the  eye  the  usual  signs  of  circulation, 
a  test  has  been  made  by  the  introduction  hypodermically  of 
a  harmless  stain  in  solution;  fluorescin  in  a  dilute  alkaline 
solution  was  used  for  the  purpose.  If  the  blood  is  moving  at 
all,  this  stain  will  show  in  the  conjunctivas  in  a  few  moments, 
"the  eye-ball  looks  like  an  emerald  in  its  orbit,"  proving 
that  there  is  still  some  heart  action  although  not  appreciable 
by  ordinary  methods  of  detection. 

Shell  Deafness. — This  is  another  traumatic  neu- 
rosis associated  with  many  other  symptoms  among 
which  are  tremor,  sweating,  increased  tendon  re- 
flexes, insomnia,  headache,  unsteady  gait,  vertigo, 
etc.  There  may  be  total  loss  of  hearing  in  one  ear 
only  and  partial  in  the  other.  Recovery  is  slow 
and  still  slower  is  the  ability  of  the  man  to  grasp 
what  is  said  to  him  or  to  remember  it.  Of  course, 
destruction  of  the  internal  ear  will  cause  total  and 
permanent  deafness,  but  if  any  sense  of  hearing 
remains  training  will  improve  it;  this  must  be 
persistent  as  in  other  nerve  affections,  with  careful 
avoidance  of  over-stimulation. 

The  nurse  who  has  had  experience  with  nervous 
cases  will  be  most  successful  in  these,  as  many 
symptoms  caused  by  air  traumatism  resemble  those 
of  hysteria  and  neurasthenia,  and  while  they  are  not 
altogether  alike  yet  the  care  of  the  cases  is  very 
similar.  Patience,  gentleness,  and  tact  are  indis- 
pensable, and  the  ingenuity  which  will  divert  the 


INJURIES  OF  THE  HEAD  137 

patient's  mind  from  himself.  If  she  is  successful, 
the  re-education  of  the  auditory  power  will  be 
steadily  progressive. 

The  results  of  accidents  with  no  external  wound, 
but  showing  in  changes  in  the  nervous  system,  are 
numerous. 

They  include  amnesia  or  loss  of  memory,  aphonia 
or  loss  of  voice,  visual  disturbances  and  even  blind- 
ness, deafness,  paralyses  and  contractures  and  many 
evidences  of  a  nerve  system  completely  demoralized. 
The  diagnosis  of  the  physical  basis  of  these  mani- 
festations is  not  always  easy,  but  as  time  goes  on  and 
experience  broadens,  it  appears  to  many  close  ob- 
servers that  actual  pathologic  changes  do  underlie 
the  majority.  This  is  not  difficult  of  understanding 
when  the  very  delicate  structure  of  nerve  tissues  is 
considered.  Such  affections  are  numberless  and.no 
attempt  is  made  to  include  them  in  these  pages. 

Although  not  surgical  cases  strictly  speaking,  they 
will,  as  injured  men,  appear  among  such  until  as- 
signed to  the  neurologic  service  now  being  rapidly 
organized. 


CHAPTER  XI 
INJURES  OF  THE  NECK  AND  SPINE 

Recognizing  the  fact  that  no  square  inch  of  the 
soldier's  body  is  missile  proof,  one  might  classify 
wounds  by  the  location  in  which  they  are  received 
and  enumerate  for  each  one  separately  a  list  of 
damaged  structures,  but  neither  time  nor  space 
permit,  and  it  is  here  attempted  only  to  call  atten- 
tion to  the  importance  and  the  vulnerability  of  the 
organs  involved,  in  certain  regions  of  the  body,  and 
to  suggest  the  general  principles  of  treatment  ap- 
propriate to  them. 

The  Neck. — It  would  be  thought  that  a  man  could 
hardly  escape  with  his  life  if  the  jugular  vein  were 
wounded,  but  such  has  been  known  to  occur  without 
proving  fatal.  Although  bullets,  etc.,  do  not  omit 
the  region  of  the  neck  in  their  effects,  they  seem 
often  to  miss  certain  vital  structures  like  the  carotid 
arteries  and  the  pneumogastric  nerves,  but  bones, 
muscles  with  their  nerves,  and  many  vessels,  are 
frequently  severely  injured.  The  attachments  of 
the  tongue  and  the  lower  jaw  may  be  torn  or  de- 
stroyed, causing  most  distressing  mutilation,  and 
still  more  when  the  muscles  of  deglutition  are  de- 

138 


INJURIES   OF  THE  NECK  AND  SPINE  139 

stroyed.  The  number  of  arteries  is  large  and  with 
their  numerous  anastomosing  branches  they  bleed 
freely,  while  fractures  of  the  cervical  vertebrae 
cause  damage  to  the  spinal  cord  with  all  its  attending 
and  far-reaching  consequences. 

The  larynx,  trachea,  pneumogastric  nerves  and  ca- 
rotid arteries  all  offer  subjects  for  fatal  injury  and  the 
sad  reason  why  many  of  these  cases  are  not  seen  in 
the  wards  is  that  the  wounds  are  fatal,  for  they  do 
undoubtedly  exist. 

INJURIES  or  THE  SPINE 

All  injuries  of  bones  cause  pain  and  more  or  less 
loss  of  motor  power,  owing  to  the  disturbance  of 
muscle  attachments,  but  injuries  of  the  bones  of  the 
spine  or  vertebra  result  in  damage  to  vastly  more 
important  structures  than  bone  and  muscle,  because 
they  involve  the  bony  canal  which  contains  the 
spinal  cord.  The  effect  of  sudden  violence  upon  the 
tissues  of  the  cord  and  spinal  nerves  may  be  serious 
without  external  evidence  of  local  injury  to  the  bones 
themselves,  but  when  lesions  of  the  vertebrae  exist 
they  do  of  necessity  involve  the  tissues  of  the  cord 
or  nerves  or  both.  Owing  to  these  close  relations 
we  include  in  the  term  "injuries  of  the  spine," 
lesions  of  the  spinal  column  and  the  spinal  cord  with 
the  nerve  roots,  and  we  measure  the  gravity  of  such 


140  WAR  NURSING 

injuries  by  their  effect  upon  other  structures  as 
evidenced  by  sensor  and  motor  changes  elsewhere. 

Concussion  of  the  spine  may  be  caused  by  accidents, 
as  the  falling  in  of  trenches  or  similar  occurrences, 
the  consequences  of  which  are  due  to  the  sudden 
jar  or  pressure  from  external  force,  producing  dis- 
ability— as  loss  of  motor  power,  impairment  or  loss 
of  sensation  and  perhaps  also  a  mental  condition 
due  to  sudden  yielding  to  the  terrors  of  the  situation. 
All  these  symptoms  are  more  or  less  temporary 
if  the  conditions  causing  them  are  soon  relieved;  for 
instance,  if  the  man  is  at  once  extricated  from  his 
dangerous  position  he  will  soon  improve,  and  gets  no 
farther  than  the  second  division  of  the  field  ambu- 
lance, or  the  "clearing  station"  at  the  farthest,  and 
may  not  come  to  the  care  of  the  nurse  at  all.  Severe 
concussion,  however,  leaves  more  serious  effects, 
being  usually  caused  by  the  forcible  impact  of  a 
missile  with  actual  damage  to  the  tissues  of  the 
spinal  cord;  the  vessels  within  the  membranes  may 
be  ruptured  or  those  within  the  cord  itself,  resulting 
in  hemorrhages  which  quickly  cause  their  effects, 
as  seen  in  loss  of  motor  power  amounting  to  paralysis, 
or  pain  more  or  less  severe.  If  the  damage  is  exten- 
sive, time  and  rest  may  see  the  man  recovered.  The 
accurate  observation  of  the  nurse,  however,  is  here 
of  value,  as  the  surgeon's  decision  in  regard  to  fur- 
ther treatment  will  be  founded  upon  the  tendency 


INJURIES  OF  THE  NECK  AND  SPINE  141 

of  symptoms,  whether  toward  improvement  or  in 
the  opposite  direction.  So  long  as  she  can  see  in- 
creasing muscle  power  and  control  of  movements, 
operation  may  not  be  advised.  On  the  contrary, 
loss  of  power  and  no  abatement  of  pain  should  be 
daily  reported  that  operation  if  decided  upon  may 
be  done  early. 

Gunshot  wounds  of  the  spine  produce  all  the  lesions 
of  both  cord  and  column  which  can  be  inflicted — 
fractures  of  the  vertebrae  with  displacement  of  bone 
and  pressure  upon  nerve  tissues;  extensive  fracture 
with  missile  lodged  in  the  canal,  and  accompanying 
hemorrhage  with  pressure  upon  the  membranes  of 
the  cord  and  upon  the  cord  itself;  crushing  of  bone 
with  pressure  of  fragments  which  have  passed 
through  the  membranes  and  are  even  imbedded  in 
the  cord. 

The  symptoms  of  all  these  will  be  paralysis,  and 
either  loss  of  sensation  or  pain,  according  to  the 
locality  and  extent  of  the  damage.  These  cases  are 
all  serious  and  demand  the  closest  observation.  The 
operation  which  may  save  the  man  to  future  useful- 
ness, or  at  least,  comfort,  will  be  decided  by  a  few 
comparatively  slight  indications.  If  only  a  few 
muscles  below  the  level  of  injuries  can  move,  if  only 
a  little  sensation  remains,  the  case  may  come  to 
operation  with  ground  for  hope  that  the  damage 
is  not  too  great  for  repair.  The  X-ray  examination 


J43  WAR  NX7RSING 

will  show  if  a  foreign  body  be  present  and  removal 
indicated.  The  importance  of  early  operation  upon 
wounds  of  the  spine  is  due  to  the  fact  that  the  deli- 
cate tissues  of  the  cord  are  quickly  injured  by  con- 
tinued pressure  and  the  impairment  of  nutrition 
which  follow  depressed  bone  or  hemorrhage.  It  is 
a  matter  of  note  that  pressure  or  the  presence  of  a 
foreign  body  in  the  tissues  of  the  brain  or  cord  in- 
fluences the  whole  circulatory  mechanism  ;  it  seems  to 
inhibit  the  processes  of  circulation,  and  to  thus  pave 
the  way  for  devitalization  of  the  tissues. 

The  spinal  cord  once  severely  damaged  will  not 
regenerate  and  loss  of  function  of  all  parts  below  the 
level  of  the  lesion  will  be  inevitable  and  incurable, 
if  once  the  tissues  become  devitalized.  The  differ- 
ence in  symptoms  between  concussion  or  con- 
tusion and  actual  lesion  of  the  cord,  resides  in 
the  temporary  character  of  the  former,  in  which  the 
paralysis,  lost  reflexes,  diminished  sensation  and 
weakened  sphincters  early  manifest  improvement, 
while  in  the  latter  case  they  grow  progressively 
marked  and  serious,  forming  a  positive  indication 
for  operation. 

Operation  once  decided  upon,  the  usual  prepara- 
tions are  made — sterilization  of  the  field  and  sterile 
dressings  applied  two  hours  before,  etc.  A  local 
anesthetic  will  probably  be  chosen  in  order  to  avoid 
the  danger  of  increased  shock,  hemorrhage,  and 


INJURIES  OF  THE  NECK  AND  SPINE  143 

chest  complications,  which  are  more  liable  to  occur 
in  these  than  in  other  major  operations  because  of 
the  possible  involvement  of  the  systemic  nerves  and 
impairment  of  function.  The  patient  may  be  placed 
for  operation  in  the  lateral  position,  therefore,  a 
firm  hard  pillow  should  be  provided,  because  while 
he  lies  upon  the  side  the  opposite  knee  and  thigh  are 
to  be  flexed  and  supported.  After  operation  he  may 
be  placed  in  the  prone  position  or  on  his  back.  The 
latter  is  the  position  of  choice,  but  in  some  cases  the 
patient  must  remain  prone.  In  either  case,  study 
his  comfort  so  far  as  possible.  Not  much  can  be 
done  to  vary  his  position,  but  little  changes  of  head 
and  feet  are  possible,  and  of  the  arms.  Pads  and 
small  pillows  may  be  brought  into  service  and  points 
of  pressure  changed  here  and  there. 

The  nurse  who  remembers  even  a  little  of  her  anat- 
omy will  not  be  puzzled  to  know  why  an  injury  of 
small  extent  can  cause  so  much  more  trouble  in  the 
cord  than  in  the  brain.  A  depressed  fracture  or 
a  foreign  body  within  the  skull,  as  a  bullet  or  frag- 
ment of  shell,  may  not  do  so  very  much  harm  if 
uninfected  and  located  at  a  reasonable  distance  from 
a  vital  part;  at  most  it  destroys  some  one  or  two 
powers  of  motion  or  sensation  but  does  not  affect 
the  whole  body.  A  lesion  of  the  same  size  in  the 
cord,  however,  involves  wide  areas  of  nerve  distribu- 


144 


WAR  NURSING 


tion  in  its  consequences. 
This  may  be  understood  by 
reference  to  the  illustration 
(Fig.  27). 

What  are  the  results  of 
serious  damage  to  the  cord? 
Paralysis  of  parts  below 
the  level,  loss  of  reflexes, 
probably  loss  of  sensation, 
and  loss  of  control  of 
sphincters.  In  addition  to 
these,  the  effects  of  gunshot 
wounds  show  invasion  by 
infected  organisms  which 
are  carried  in  by  missiles, 
etc.;  and  sepsis  spreads 
rapidly  along  the  membranes 
so  that  it  is  here  more  than 
elsewhere,  a  menace. 

One  of  the  dangerous  com- 
plications of  spinal  cord  in- 
jury is  septic  infection  of  the 
genito-urinary  tract,  to  avoid 


FIG.  27. — The  brain  and  spinal  cord.  Serious  injury  in  any  por- 
tion of  the  spine  above  the  I2th  dorsal  vertebrae  cuts  off  motor 
and  sensory  nerve  fibers  which  are  connected  with  many  parts  of 
the  body  below  that  level.  The  higher  the  location  of  the  wound 
the  wider  will  be  the  area  affected,  since  more  nerve  fibers  are 
contained  in  the  tracts  in  the  upper  part  of  the  cord.  (Quain,  after 
Bourgery). 


INJURIES  OF  THE  NECK  AND  SPINE  145 

Which  the  greatest  care  in  nursing  is  necessary  and 
even  this  may  not  be  successful,  therefore,  the  risk 
of  operating  is  worth  undertaking. 

Another  distressing  condition  calling  for  operation 
in  an  otherwise  desperate  case,  is  intense  pain  caused 
by  pressure  of  fragments  of  bone  imbedded,  prob- 
ably, in  sensory  nerve  roots  and  not  controllable 
by  ordinary  measures. 

Nothing  can  be  more  gratifying  than  the  success- 
ful operation  upon  the  spine.  The  removal  of 
laminae  (laminectomy)  reveals  the  cause  of  the  symp- 
toms; as  depressed  fragments  of  bone,  or  it  may  be,  a 
bullet  and  hemorrhage,  with  all  the  distribution  of 
symptoms  which  have  been  mentioned.  The  re- 
moval of  these  will  be  followed  by  recovery  pro- 
vided complicating  conditions  elsewhere  are  not  too 
serious.  In  one  case  reported  in  Major  Hull's 
book,  "Surgery  in  War,"  a  portion  of  shell  had 
fractured  the  laminae  of  the  5th  cervical  vertebra 
and  a  piece  of  bone  half  an  inch  square  was  press- 
ing upon  the  cord.  All  four  limbs  were  paralyzed 
and  there  was  loss  of  control  of  bladder  and  rectum. 
Twenty-four  hours  after  operation  signs  of  recovery 
appeared,  which  later  was  complete.  Many  such 
instances  might  be  related  of  spinal  surgery  in  the 
present  war. 

Injuries  of  Spinal  Nerves. — Wounds  of  the  ex- 
tremities almost  always  involve  nerves.  The  injuries 

10 


146  WAR  NURSING 

vary  in  severity,  from  bruising  and  shock  to  complete 
severance,  and  the  results  accord  with  the  lesion,  the 
nerve  which  is  simply  shocked  showing  some  paraly- 
sis from  which  it  soon  recovers,  but  no  permanent 
injury  unless  the  bruise  is  severe  enough  to  cause 
local  irritation,  when  an  area  of  fibrous  tissue  may 
develop  which  will  cause  more  lasting  weakness  and 
probably,  later,  pain.  A  partially  divided  nerve  is 
usually  involved  in  the  damage  sustained  by  sur- 
rounding tissues  and  a  painful  condition  will  be 
caused  by  the  adhesions  and  scar  tissue  which  enclose 
it.  If  the  nerve  is  completely  divided,  the  peripheral 
portion  will  degenerate  if  left  to  itself,  while  the  por- 
tion still  connected  with  its  centers  will  be  able  at 
times  to  grow,  sometimes  to  an  astonishing  extent. 

Nerves  of  every  part  of  the  body  suffer  from 
wounds  in  war  but  most  frequently  those  of  the  ex- 
tremities, especially  the  ulnar  and  radial  in  the  arm 
and  the  sciatic  in  the  thigh  (Fig.  28). 

Injuries  by  fragments  of  bone  or  other  foreign 
bodies  will  receive  attention  when  the  wound  is  first 
treated,  when,  of  course,  all  these  will  be  removed. 
As  nearly  all  gunshot  wounds  are  infected  even  if  only 
slightly,  this  fact  is  taken  into  account  in  deciding 
upon  the  time  for  operation  upon  injured  nerves 
themselves. 

If  a  damaged  nerve  is  not  recovering  the  fact  may  be 
known  by  loss  of  motor  power,  perhaps  traceable  to 
the  pressure  of  scar  tissue. 


INJURIES  OF  THE  NECK  AND  SPINE  147 

Trophic  changes  are  visible  effects  of  nerve  injury, 
as  seen  in  the  condition  of  the  finger  nails  which  are 
curved  and  brittle,  and  the  rapid  growth  of  hair  over 


Ulnar  nerve  and  artery 
Radial  nerve  and 
artery 


Branches  to  hand 


FIG.  28. — The  forearm,  anterior.     Showing  ulnar  and  radial  nerves 
and  their  relations. 

the  parts  supplied  by  the  affected  nerve;  these 
accompany  loss  of  sensation.  A  tendency  to  ulcera- 
tion  of  the  skin  upon  very  slight  injury  is  due  to  the 


148  WAR  NURSING 

same* cause;  hot  water  which  would  not  burn  any 
other  portion  of  the  skin  may  produce  a  blister  and 
ulceration.  (An  important  part  of  the  treatment  of 
this  local  condition  is  to  keep  the  lesions  warm  and 
protected  from  infection.) 

Vasomotor  disturbance  is  shown  by  sweating  over 
the  parts  supplied  by  the  nerve;  for  instance,  if  the 
median  nerve  is  damaged,  the  part  of  the  hand  sup- 
plied by  it  becomes  red  and  sweats  continuously.  It 
has  even  been  observed  that  half  of  the  ring  finger 
may  be  moist  while  the  other  half  is  dry. 

The  sensory  condition  in  the  skin  supplied  by  a 
damaged  nerve  should  always  be  watched  and 
reported.  Knowledge  thus  gained  is  important  in 
the  light  of  possible  operation.  Burning,  throbbing 
and  aching  sensations  may  exist  and  changed  re- 
sponse to  pressure,  temperature  and  touch. 

The  electrical  reactions  of  the  muscles  or  nerves 
will  be  tested  by  the  physician. 

Operations  will  be  done  for  the  purpose  of  reliev- 
ing severe  pain  or  for  restoring  the  use  of  muscles, 
by  either  freeing  from  damaged  tissues  the  nerves 
which  are  distributed  to  them,  or  by  splicing  and 
suturing  these  with  other  nerves  which  are  uninjured. 

NOTES. — After  the  operation  of  nerve-anastomosis 
it  is  of  the  utmost  importance  that  the  limb  be  kept 
perfectly  quiet. 

Any  motion  or  position  which  would  cause  even 


INJURIES  OF  THE  NECK  AND  SPINE  149 

the  slightest  stretching  must  be  forbidden,  and 
although  massage  and  passive  movements  will  be 
begun  as  early  as  possible,  nothing  of  the  sort  should 
be  attempted  without  explicit  orders  from  the 
physicians. 


CHAPTER  XII 
WOUNDS  OF  THE  CHEST  AND  ABDOMEN 

THE  CHEST 

Brief  Review  of  Structure  and  Contents. — The 
boundaries  of  the  chest  or  thorax  are  the  spinal  col- 
umn at  the  back,  the  sternum  in  front,  and  the  ribs 
at  the  sides,  with  the  intercostal  muscles  in  the  inter- 
costal spaces  and  the  diaphragm  in  place  of  a  floor. 
It  is  deeply  covered  behind  by  the  muscles  of  the 
back,  while  the  anterior  serratus,  the  broad  abdom- 
inal muscles,  and  the  pectorals  are  closely  applied 
to  the  sides  and  front. 

The  intercostal  arteries  and  nerves  are  protected 
from  injury  ordinarily,  by  their  position  under  the 
borders  of  the  ribs,  and  are  severed  only  when  the 
bones  are  fractured  or  in  a  wound  caused  by  pene- 
tration in  an  upward  direction. 

All  muscles  which  are  attached  to  the  ribs  are 
muscles  of  respiration;  the  intercostals  have  consider- 
able power,  but  the  diaphragm  is  most  important. 
When  it  contracts  it  is  depressed,  increasing  the 
depth  of  the  thoracic  cavity  (while  the  other  muscles 
broaden  the^cavity  by  lifting  the  ribs)  and  thus  room 

150 


WOUNDS  OF  THE  CHEST  AND  ABDOMEN         151 

is  made  for  expansion  of  the  lungs  in  inspiration. 
As  the  ribs  fall  and  the  diaphragm  ceases  to  contract, 


FIG.  29. — Thoracic   and   abdominal   viscera,    anterior.     (Deaver.) 

it  rises,  returning  to  its  dome  shape,  and  the  air  is 
pressed^from  the  lungs  in  expiration,  therefore  paraly- 


152 


WAR  NURSING 


sis  of  this  important  muscle,  or  anything  which  pre- 
vents its  contraction  is  a  serious  matter  for  the  patient 
to  whom  it  occurs. 


The  thoracic  viscera  are  the  esophagus,  trachea  and 
bronchi,  lungs,  and  heart.    The  esophagus  lies  close 


WOUNDS  OF  THE  CHEST  AND  ABDOMEN        153 

to  the  spinal  column;  and  the  trachea  is  in  front  of  the 
esophagus,  dividing  into  the  large  bronchi,  whose 


FIG.  31. — The  phrenic  nerves,  right  and  left,  run  downward  on 
either  side  of  the  great  vessels  and  the  heart.     (After  Morris.) 

branches  are  the  bronchial  tubes.  The  heart  and 
large  vessels  are  in  the  anterior  and  middle  part  of 
the  thoracic  cavity  (Fig.  32). 


154  WAR  NURSING 

The  heart  is  wrapped  in  the  pericardium,  and  each 
lung  is  wrapped  in  a  pleural  sac  which  is  placed  be- 
tween the  lung  and  the  chest  wall.  An  incision 
through  that  part  of  the  wall  which  is  bounded  by  the 
ribs  would  pierce  the  costal  pleura  and  open  the 
pleural  cavity.  A  wound  of  the  lung  would  injure 
the  pulmonary  pleura  as  well  (Fig.  30). 

The  large  nerves  in  the  thoracic  cavity  are  the  vagi, 
lying  close  to  the  esophagus,  the  sympathetic,  whose 
branches  form  cardiac  and  pulmonary  plexus,  and 
the  two  phrenic  nerves  right  and  left  which,  arising 
in  the  neck  from  the  cervical  plexus  pass  downward 
into  and  through  the  thorax  on  either  side  of  the 
pericardium  to  the  diaphragm.  Their  importance  is 
obvious  (Fig.  31). 

The  mediastinum  is  the  space  between  the  lungs. 
In  it  all  of  the  thoracic  viscera  except  the  lungs  are 
situated,  the  most  important  being,  of  course,  the 
heart  and  great  blood-vessels  with  their  nerve 
plexuses. 

WOUNDS  OF  THE  CHEST  WALL 

These,  if  uninf ected,  are  serious  only  because  of  the 
involvement  of  other  structures.  For  example,  frac- 
ture of  the  ribs  is  accompanied  by  hemorrhage  from 
intercostal  arteries  and  laceration  of  intercostal 
nerves,  while  sharp  points  or  rough  edges  of  the 
bones  injure  the  lung  tissue. 


WOUNDS  OF  THE  CHEST  155 

A  comparatively  simple  wound  in  the  region  of  the 
lower  ribs  will  cause  rigidity  of  abdominal  muscles 
(which  are  attached  to  these  ribs)  and  suggest  a 
penetration  of  the  abdomen.  The  patient  should 
be  kept  quiet  even  if  no  other  symptom  appears 
until  observation  has  decided  the  location  of  the 
internal  injury. 

The  impact  of  a  missile  at  short  range  or  an  ap- 
parently slight  wound  without  penetration  may  still 
bruise  the  nerves  and  lung  and  perhaps  cause  spitting 
of  blood.  Temporary  inhibition  of  the  heart's  action 
and  unconsciousness  may  easily  occur  when  no  ex- 
ternal mark  is  seen.  Fractured  ribs  with  pleurisy  and 
(rarely)  pneumonia  are  common  and  require  the 
treatment  with  which  the  nurse  is  already  familiar — 
strapping,  enforced  rest,  ice  bags  if  the  lung  is  in- 
jured, careful  observation,  record  of  pulse,  tem- 
perature and  especially  respirations,  and  all  other 
symptoms. 

Wounds  of  the  posterior  wall  which  involve  the 
spine  and  spinal  cord,  have  been  mentioned  and 
their  consequences  indicated  (p.  141). 

WOUNDS  OF  THORACIC  VISCERA 

Although  the  thorax  (or  chest)  is  occupied  entirely 
by  organs  which  are  essential  to  life,  many  injuries 
in  this  part  are  sustained  without  a  fatal  result. 

If  they  are  sufficiently  serious  to  bring  the  man  to 


156  WAR  NURSING 

the  hospital  he  will  present  a  condition  of  shock,  and 
if  infection  has  already  occurred  it  will  involve  the 
pleura  and  the  case  will  ultimately  become  one  of 
empyema.  Other  symptoms  will  be  influenced  by 


FIG.  32. — The  lungs  with  heart  between  them. 

the  location  of  the  wounds  and  the  character  of  the 
missile. 

Here,  as  elsewhere,  rifle  bullets  and  shrapnel  balls 
cause  least  injury  because  the  wounds  are  straight 
punctures.  If  they  penetrate  the  lung  they  meet  so 
little  resistance  that  they  pass  directly  through, 
leaving  a  small  track  only.  Pieces  of  shrapnel  shell 


WOUNDS  OF  THE  CHEST  157 

cause  more  damage,  and  from  their  shape  are  more 
likely  to  be  retained  in  the  injured  tissues.  Again, 
because  of  their  shape  they  lose  velocity  and  the 
effects  are  spreading  (see  p.  n). 

Recalling  the  position  of  the  organs  in  the  medias- 
tinum and  their  importance  (Fig.  32)  it  is  readily 
understood  that  the  nearer  to  the  median  line  the 
bullet  enters,  the  greater  the  damage. 

Also,  just  outside  of  the  mediastinum  the  bulk  of 
lung  tissue  is  greatest  and  the  vessels  are  large. 
The  severe  symptoms  caused  by  injuries  of  large 
blood-vessels,  however,  do  not  always  come  on  at 
once.  Remembering  this,  observe  carefully  any 
signs  of  increasing  weakness,  or  shallow  breathing, 
and  provide  that  the  patient  shall  not  be  disturbed 
in  any  way.  He  should  rest  in  the  semi-sitting  posi- 
tion and  be  absolutely  quiet.  No  physical  exertion 
is  to  be  allowed.  If  it  is  necessary  to  remove  cloth- 
ing it  should  be  cut  off  rather  than  removed  in  the 
usual  way.  Every  precaution  of  this  kind  should  be 
continued  until  the  danger  of  severe  hemorrhage  is 
passed  and  the  patient  can  be  transferred  to  a  base 
hospital. 

Where  there  is  great  damage  to  the  lung  tissue  the 
patient  will  be  shocked  to  the  verge  of  collapse.  The 
heart  sounds  will  be  hardly  audible  for  hours;  the 
pulse  will  be  almost  imperceptible  with  a  rate  of 
140  or  more;  respirations  will  be  painful  and  difficult, 


158  WAR  NURSING 

shallow  and  frequent  even  to  60  or  80  per  minute, 
causing  a  distressing  sensation  of  want  of  air. 

Spitting  of  blood  is  common  and  hemorrhage  is  to 
be  apprehended. 

The  temperature  rises  after  recovery  from  shock, 
varying  between  100  and  102°  for  a  few  days  usually. 
If  infection  has  taken  place  it  reaches  a  higher  mark, 
assuming  a  septic  character  and  the  systemic  effects 
are  similar  to  those  in  other  parts  of  the  body. 
When  pus  is  formed  drainage  will  be  instituted. 

NOTE. — Wounded  lung  is  exposed  to  infection 
from  two  directions;  first,  by  organisms  carried  in 
with  the  missile  and  again  by  those  in  the  atmosphere 
which  is  inspired  through  the  mouth,  therefore  en- 
deavor especially  to  protect  the  patient  from  dust  or 
other  atmospheric  impurities  for  the  reason  that  they 
add  to  the  danger  which  already  exists. 

The  appearance  of  the  patient  and  the  temper- 
ature as  well  are  much  like  that  of  pneumonia,  with 
the  respirations  rapid  and  shallow  and  the  pulse  run- 
ning at  about  a  hundred,  and  the  "pneumonic flush. " 
Cough  is  troublesome  with  free  expectoration  of 
purulent  substances  and  the  movements  of  respira- 
tion are  restricted.  In  cases  which  recover  the  dura- 
tion of  the  symptoms  will  vary  from  ten  days  to  a 
month.  With  suppuration  going  on  in  the  lung  the 
greatest  care  must  be  taken  to  persuade  the  patient 


WOUNDS  OF  THE  CHEST  159 

to  exercise  cleanliness.  The  internal  remedies  se- 
lected will  be  such  as  to  act  as  disinfectants  and  more 
particularly  as  deodorizers,  such  as  creosote  given 
by  mouth  and  by  inhalation,  turpentine,  etc. 

NOTE. — In  administering  the  inhalation  it  is  not 
necessary  to  cover  the  patient's  head  as  is  usually 
done.  It  is  enough  if  his  nose  and  mouth  are  in- 
cluded in  the  funnel  which  conveys  the  steam. 
Otherwise  he  emerges  with  moist,  sensitive  skin, 
damp  hair  or  beard,  and  an  almost  inevitable  chilling 
of  the  head  and  neck  succeeds  the  treatment. 

The  operations  for  which  preparation  is  most  fre- 
quently to  be  made  are  aspiration  and  resection  of 
ribs.  In  the  latter  case,  the  care  of  the  drainage  tube 
is  of  first  importance.  Sometimes  this  tube  is  con- 
nected with  another,  long  and  flexible,  which  leads 
to  a  basin  of  mild  antiseptic  solution.  When  the 
patient  coughs  air  from  the  lung  is  forced  through 
the  tube  by  the  expiratory  act,  and  as  a  rather  deeper 
inspiration  follows  a  little  of  the  fluid  will  be  drawn 
up  into  the  tube,  so  that  it  is  partially  filled,  and 
sealed  with  antiseptic  solution.  The  motion  of 
suction  thus  caused  is  beneficial  as  it  tends  to  assist 
the  free  flow  of  the  material  to  be  drained  away  from 
the  wound. 

COMPLICATIONS 

Hernia  of  the  lung  sometimes  occurs,  for  which 
moist,  sterile  dressings  (kept  always  moist)  are  used. 


l6o  WAR  NURSING 

Constantly  and  persistently  followed  up,  this  meas- 
ure has  accomplished  satisfactory  results. 

Bronchitis  is  serious,  requiring  most  scrupulous 
care  and  every  precaution  against  exposure  to  drafts 
of  air,  especially  if  it  is  laden  with  irritating  parti- 
cles which  would  cause  coughing.  Pneumonia  is 
still  more  serious.  It  exhausts  the  patient's  vitality 
so  that  he  improves  slowly,  if  at  all.  Abundance  of 
fresh  air  is  important,  but  on  no  account  must  he  be 
allowed  to  feel  chilled.  In  a  badly  damaged  lung 
abscess  will  probably  form,  especially  if  other  organs, 
as  the  liver,  be  included  in  the  track  of  the  missile. 

The  occurrence  of  pneumothorax  or  escape  of 
air  from  the  lung  into  the  thorax,  requires  that  the 
patient  be  placed  in  a  semi-sitting  position  unless  it 
is  impossible  to  make  it  comfortable  for  him,  in  which 
case  he  himself  must  decide  how  many  pillows  the 
nurse  shall  place  under  his  head  and  shoulders.  Rest 
is  here  more  than  ever  imperative  for  at  least  ten 
days  or  two  weeks,  as  muscular  effort  will  cause  an 
increasing  volume  of  air  to  pass  into  the  chest  with 
each  act  of  breathing. 

Unfortunately  this  is  often  a  fatal  complication. 


It  is  quite  different  from  artificial  pneumothorax  produced 
for  the  purpose  of  compressing  a  diseased  lung  which  is 
not  wounded,  by  the  introduction  of  air  or  gas  into  the 
thorax  from  without. 


WOUNDS  OF  THE  CHEST  l6l 

Hemothorax  or  hemorrhage  into  the  pleural 
cavity  presents  the  usual  signs  of  hemorrhage  else- 
where, with  air  hunger;  the  bleeding  is  not  always 
rapid  and  symptoms  do  not  develop  suddenly,  there- 
fore one  need  not  be  taken  by  surprise. 

It  is  a  frequent  complication.  If  moderate  in 
amount  the  pulse  rate  will  diminish  to  85  or  90  in  a 
few  days,  the  respirations  will  number  less  than  30 
and  the  temperature  also  will  mark  the  improve- 
ment ;  but  when  the  amount  of  the  effusion  is  greater 
—perhaps  displacing  the  heart — the  pulse  rate  goes 
above  100° — and  respirations  reach  to  35  or  more  per 
minute;  then  aspiration  may  be  performed  and 
several  ounces  of  blood  withdrawn. 

The  combination  of  pneumothorax  with  hemothorax 
is  unfavorable,  increasing  both  the  distress  and  the 
danger  of  the  patient.  When  air  is  entering  through 
an  external  wound  in  the  chest  wall  an  operation  is 
sometimes  done  for  closing  the  wound  either  entirely 
or  partially,  to  give  relief.  A  firm  bandage,  or  strap- 
ping over  the  dressing,  may  be  resorted  to  for  the 
same  purpose. 

Infection  of  the  fluid  in  hemothorax  is  common, 
and  serious;  the  symptoms  to  be  watched  for  are 
pallor  of  the  face  with  perhaps  a  flushed  area,  dry 
tongue,  anxious  expression,  elevation  of  pulse,  res- 
piration and  temperature,  and  perhaps  nausea  or 
vomiting — in  other  words,  the  signs  of  empyema. 


162 


WAR  NURSING 


Again,  aspiration  will  probably  be  performed,  and 
perhaps  resection  and  drainage. 

Involvement  of  abdcminal  organs  in  the  wound 
which  invades  the  thorax.  The  possibility  of  this 
complication  will  be  recognized  by  recalling  the  fact 
that  the  floor  of  the  thorax  (the  diaphragm)  is  dome 


FIG.  33. — The  diaphragm.     Dotted  lines  indicate  descent  in  con- 
traction.    (Holden.) 

shaped,  rising  to  the  level  of  the  fifth  rib  on  either 
side  of  its  central  tendon  (Fig.  33).  The  abdominal 
organs  which  lie  immediately  beneath  the  hollow 
of  this  dome  are  inevitably  wounded  by  a  missile 
which  enters  transversely  into  the  lower  part  of  the 
thorax,  as  for  example  the  liver,  stomach,  or  spleen. 
In  this  situation,  however,  there  is  but  a  thin  portion 
of  lung  to  be  pierced,  but  a  missile  which  takes  an 


WOUNDS  OF  THE  ABDOMEN  163 

oblique  direction  either  upward  or  downward,  would 
injure  not  only  an  abdominal  organ  but  a  greater 
bulk  of  lung  tissue;  the  consequences  would  be 
doubly  serious  and  often  fatal.  To  the  shock  of 
thoracic  is  added  that  of  abdominal  injury,  with 
perhaps  hemorrhage  of  grave  character,  and  the  dan- 
gers accompanying  the  laceration  of  organs. 

All  of  the  complications  named  constitute  grave 
cases,  requiring  much  care  and  long  treatment  with 
special  attention  to  diet  and  supporting  measures. 

WOUNDS  OF  THE  ABDOMEN 

In  the  case  of  wounds  of  the  abdomen  the  possible 
complications,  owing  to  the  number  of  vital  organs  in 
close  juxtaposition,  present  serious  problems  to  the 
surgeon  and  therefore  to  the  nurse  as  well.  A  wound 
with  a  non-infected  weapon  in  a  non-poisonous  atmos- 
phere, administered  by  a  keen  thrust  through  cloth- 
ing not  specially  infected,  might  not  leave  serious 
consequences,  but  in  the  present  war  these  conditions 
do  not  exist.  Infection  and  sepsis  are  to  be  expected, 
the  patient's  condition  carefully  watched,  the  symp- 
toms scrupulously  noted  and  reported. 

NOTE. — All  abdominal  wounds  produce  severe 
shock. 

Brief  Review  of  the  Nine  Areas  of  the  Abdomen  and 
Their  Contents  (Fig.  36). — On  the  anterior  surface  of 
the  abdomen  observe  the  linea  alba  between  the  two 


164 


WAR  NURSING 


rectus  muscles,  and  the  semilunar  lines  (or  linece 
semilunar  es)  at  the  sides  of  the  recti.     The  transverse 


FIG.  34. — Showing  the  linea  alba,  the  semilunar  and  the  transverse 
lines.     In  a  muscular  subject  they  are  very  evident. 

lines  (Una  transverse)  may  be  seen  when  the  recti 
contract.  An  important  outline  is  made  by  the  lower 
ribs,  between  the  thorax  and  abdomen,  the  two  sides 


WOUNDS  OF  THE  ABDOMEN 

meeting  in  the  subcostal  angle  just  below  the  sternum. 
The  scrobiculus  cordis,  or  "pit  of  the  stomach,"  is  a 
slight  depression  at  the  very  point  of  this  angle, 


caused  by  a  weak  spot  in  the  attachment  of  the  ab- 
dominal muscles.  If  the  abdomen  is  greatly  dis- 
tended, the  depression  disappears  (Fig.  35). 


i66 


WAR  NURSING 


When  abdominal  distention  has  reached  the  point 
of  obliteration  of  the  scrobiculus  cordis,  the  action  of 


FIG.  36. — Thoracic  and  abdominal  viscera,  anterior.     (Deaver.) 

the  diaphragm  is  embarrassed  and  respiration  is  in- 
terfered with  (see  p.  151).    Paralysis  of  intestinal 


WOUNDS  OF  THE  ABDOMEN  167 

walls,  as  in  the  relaxation  and  loss  of  peristalsis  in 
shock  and  some  major  operations,  is  a  frequent 
cause  of  this  unfortunate  complication. 

The  abdominal  viscera  (Fig.  36)  are  the  stomach, 
intestines,  liver,  spleen,  pancreas,  kidneys,  and  adrenal 
bodies.  The  great  vessels  are  at  the  back.  The 
sympathetic  ganglia  are  at  the  sides  of  the  vertebrae, 
with  the  celiac  and  other  plexuses  situated  on  the 
large  vessels. 

The  kidneys  are  behind  all  of  the  other  viscera,  and 
the  ureters  run  down  close  to  the  posterior  wall  of  the 
abdomen  on  their  way  to  the  bladder. 

The  receptaculum  chyli,  or  beginning  of  the  tho- 
racic duct,  is  in  front  of  the  second  lumbar  verte- 
bra. The  inferior  vena  cava  lies  on  the  right  side 
of  the  aorta. 

The  principal  organ  in  the  epigastric  region  is  the 
stomach;  in  the  right  hypochondriac,  the  liver;  in  the 
left  hyp  chondriac,  the  spleen.  The  umbilical  region 
is  occupied  mostly  by  small  intestines.  The  right 
and  left  kidneys  are  in  the  two  lumbar  regions,  with 
the  ascending  colon  in  front  of  the  right,  and  the  de- 
scending colon  in  front  of  the  left  kidney.  The  cecum 
and  appendix  are  in  the  right  inguinal  region;  the 
bladder,  in  the  hypogastric. 

Each  region  contains  portions  of  several  viscera  in 
addition  to  those  named.  Scarcely  any  organ  save 
the  spleen  and  cecum  can  be  said  to  belong  to  but  one 


1 68  WAR  NURSING 

region.     The  small  intestine,  for  example,  is  seen  in 
all  but  those  of  the  upper  zone. 

The  peritoneum  is  a  closed  sac  of  serous  membrane  like  a 
water-bag,  which  is  placed  between  the  abdominal  wall  and 
abdominal  viscera.  It  is  practically  in  front  of  the  viscera, 
and  tucked  in  around  them  at  the  sides.  One  side  of  the  sac 
is  closely  applied  to  the  abdominal  wall,  and  is  called  the 
parietal  peritoneum,  while  the  other  side  is  fitted  to  the  vis- 
cera, and  called  the  visceral  peritoneum.  Normal  peritoneum 
is  perfectly  transparent,  and  the  viscera  are  plainly  seen 
through  the  visceral  layer.  The  peritoneal  cavity  contains 
little  serous  fluid  and  nothing  else. 

An  incision  in  the  abdominal  wall,  including  the 
parietal  peritoneum,  opens  the  peritoneal  cavity. 
An  incision  into  one  of  the  organs  involves  the  visceral 
peritoneum,  with  these  exceptions: 

The  posterior  surface  of  the  liver. 

The  posterior  surface  of  the  ascending  colon.  The 
kidneys. 

The  transverse  portion  of  the  duodenum.  The 
front  of  the  bladder  behind  the  symphysis.  These 
parts  have  no  serous  layer. 

It  is  stated  by  some  surgeons  in  the  present  war 
that  wounds  caused  by  bullets  passing  through  the 
three  medial  regions  (the  epigastric,  umbilical  and 
hypogastric)  are  more  serious  than  those  of  the  lateral 
regions  (the  hypochondriac,  lumbar  and  inguinal), 
and  that  those"  of  the  umbilical  region  are  most 
serious  of  all.  Others  consider  the.  "side  to  side" 


WOUNDS  OP  THE  ABDOMEN 


169 


wound,  lower  down,  more  dangerous,  and  equally 
so,  the  antero-posterior  buttock  and  hip  wounds. 
Recall   the  organs   which  occupy   the   umbilical 


region — several  coils  of  small  intestine  are  there  to 
be  punctured — always  a  serious  accident;  the  omen- 
turn  in  front  and  the  mesentery  behind  with  its 


170  WAR  NURSING 

many  vessels,  will  be  damaged;  the  pancreas  may  be 
injured,  large  arteries  and  nerves  may  be  severed  and 
the  duct  of  the  pancreas  or  liver  as  well  (see  Fig.  37). 
Operations  for  wounds  in  this  region  are  therefore  very 
serious;  the  patient  may  be  already  in  a  critical 
condition  and  collapse  is  to  be  apprehended.  There- 
fore preparations  must  be  made  for  shock,  and  for 
hemorrhage  in  which  the  symptoms  are  quite  similar, 
for  here  are  many  large  arteries  with  a  network  of 
anastomosing  branches. 

When  the  condition  is  very  grave,  operation  will 
not  be  attempted. 

In  the  epigastric  area  there  are  few  structures  to 
be  injured  (if  the  large  vessels  escape) ;  probably  the 
stomach  will  be  punctured,  but  this  although  a 
serious  is  not  necessarily  a  fatal  wound,  especially 
when  it  is  inflicted  while  the  stomach  is  empty,  as 
is  apt  to  be  the  case  in  battle. 

In  the  hypogastric  region,  wounds  of  the  bladder, 
rectum  and  other  portions  of  the  intestine  are  more 
serious.  In  the  lateral  regions  the  wounded  liver 
or  kidney  may  recover  without  operation.  The 
colon  may  be  punctured  but  with  less  probability  of 
general  peritonitis  than  in  the  case  of  the  small  intes- 
tine, although  the  escaping  fecal  contents  are  more 
likely  to  cause  sepsis. 

Even  without  the  additional  strain  of  operation, 
abdominal  injuries  produce  severe  shock.  Due  to 


WOUNDS   OF  THE  ABDOMEN  171 

this  and  the  hemorrhage  which  so  frequently  occurs, 
the  white  face,  quick  breathing,  and  rapid  small  pulse 
which  always  mean  trouble,  will  be  present  even  with 
no  great  amount  of  pain  or  tenderness.  These 
symptoms  alone  may  present  themselves  but  they 
call  for  constant  watchfulness.  They  are  sometimes 
due  to  a  marked  degree  of  the  rigidity  of  abdominal 
walls  which  is  Nature's  defensive  attitude  when  the 
muscles  are  protecting  a  wounded  organ.  If  the 
same  symptoms  exist,  however,  without  pain  and 
tenderness  or  rigidity,  they  more  definitely  suggest 
hemorrhage,  and  in  a  majority  of  fatal  endings  from 
abdominal  wounds,  hemorrhage  is  the  cause  of 
death.  If,  after  some  days  local  pain  and  tenderness 
appear — with  a  rise  of  temperature — look  out  for  peri- 
tonitis and  again,  perhaps  with  hemorrhage.  This 
inflammation  or  peritonitis  accompanied  with  jaun- 
dice, suggests  a  lesion  of  the  liver  and  bile  ducts  and 
the  escape  of  bile  into  the  peritoneal  cavity. 

If  the  kidneys  or  the  bladder  are  wounded  blood 
will  be  discovered  in  the  urine  and  probably  severe 
pain  will  accompany  micturition.  Since  it  has  been 
decided  that  patients  with  abdominal  injuries  have 
a  much  better  chance  for  recovery  with  early  opera- 
tion, special  measures  have  been  instituted  to  ensure 
the  possibility  of  this  proceeding  and  an  operating 
room  will  be  in  constant  readiness. 

The  multitudinous  duties  of  the  operating  nurse 


172  WAR  NURSING 

are  well  defined  and  have  been  already  briefly  out- 
lined. Each  class  of  cases  requires  its  own  proced- 
ures and  each  surgeon  has  his  own  method ;  all  will 
be  quickly  learned  in  the  emergencies  of  the  circum- 
stances, and  they  can  be  learned  in  no  other  way. 

Various  kinds  of  missiles  may  be  lodged  in  the 
abdomen  without  causing  symptoms  but  discover- 
able only  by  the  use  of  the  X-ray.  Bullets  will  prob- 
ably not  be  removed  under  those  circumstances, 
but  fragments  of  shell  or  of  shrapnel  are  not  safely 
left  as  they  may  cause  abscess,  or  erosion  of  the  blood- 
vessels, with  their  consequences. 

After-care  of  Operative  Cases. — The  patient  is  to 
be  placed  comfortably  in  a  half-sitting  position,  with 
the  knees  somewhat  flexed,  the  tension  of  the  abdomi- 
nal muscles  being  thus  relaxed.  This  will  direct 
the  spread  of  the  peritonitis,  if  it  occurs,  to  the  lower 
part  of  the  abdomen  away  from  the  movable  organs. 
No  solid  food  should  be  given,  but  water  if  there 
is  great  thirst,  is  granted  in  tablespoonful  doses 
every  ten  or  fifteen  minutes,  even  if  perforation  of 
the  bowel  is  suspected,  as  it  is  rapidly  absorbed  in 
the  upper  part  of  the  alimentary  tract.  Even  with 
hemorrhage,  water  may  be  given  in  this  way,  be- 
cause the  ready  absorption  will  meet  the  demand  of 
the  system  for  fluid  which  could  not  be  safely  given 
by  saline  transfusion  or  hypodermoclysis.  Liquid 
food  may  be  given  .at  once  if  .the  wound  is  only  that 


WOUNDS  OF  THE  ABDOMEN  173 

of  a  solid  organ  or  if  it  is  known  to  be  in  the  lower  part 
of  the  bowel.  Pituitary  extract  will  probably  be 
ordered  to  overcome  shock  and  prevent  distention 
of  the  bowel. 

No  laxative  will  be  ordered  for  five  or  six  days 
nor  the  administration  of  an  enema,  as  even  a 
low  enema  will  cause  peristaltic  movements  of 
the  bowel,  extending  far  above  the  rectum.  When 
the  time  arrives  a  safe  proceeding  is  the  injection  of 
a  small  amount  of  glycerine  in  the  rectum  preceded 
by  an  injection  of  pituitary  extract.  The  surgeon 
may  consider  it  necessary,  later,  to  order  calomel  in 
Y±  gr-  doses  every  hour  up  to  five  grains.  Milk  is 
not  advised  as  food  in  these  cases,  except  in  very 
small  quantities,  on  account  of  the  flatulence  some- 
times caused  by  it,  and  the  bulky  stool.  Benger's 
food  made  without  milk,  meat  juice,  or  meat  es- 
sences are  more  suitable,  eggs  are  quite  allowable, 
being  digested  in  the  stomach  and  duodenum  and 
almost  entirely  absorbed  before  reaching  the  bowel. 
Solid  food  never — until  after  the  expiration  of  a 
week ;  perforation  and  hemorrhage  have  been  caused 
here  as  in  typhoid  fever  by  too  early  use  of  solid 
food. 

The  patient  is  to  be  absolutely  at  rest — no  exer- 
tion allowed  for  any  purpose;  he- is  not  to  raise  his 
head  while  lying  supine  or  while  half  sitting  be- 
cause involuntary  action  of  the  abdominal  muscles 


174  WAR  NURSING 

is  unavoidable  even  in  so  slight  an  exertion~as"lift- 
ing  the  head  from  the  pillow.  Lift  it  for  him,  by  a 
hand  slipped  underneath  the  pillow;  .treat  him  as 
though  he  already  had  a  hemorrhage;  perhaps  he 
has  and  the  symptoms  are  not  showing.  Watch 
unceasingly  for  blanching  of  the  face,  increasing 
pulse  rate,  or  difficulty  in  breathing.  Know  the  lo- 
cation of  organs;  instruct  assistants,  so  that  they 
may  know  the  possible  dangers  and  emergencies  to 
be  prepared  for. 

The  above  directions  apply  also  to  those  whose 
desperate  condition  classes  them  as  non-operable. 
Such  will  probably  be  the  nurse's  own  patient  and 
she  will  feel  a  justifiable  pride  in  her  work,  if  happily 
she  should  pull  him  through  to  safety  after  all.  It 
has  been  known  that  the  assiduous  care  of  a  nurse 
has  saved  the  life  of  a  patient  with  a  supposedly 
fatal  wound  of  the  abdomen. 

NOTE. — Abdominal  operations  in  war  time  are  far 
more  serious  than  in  time  of  peace. 

First,  the  condition  of  the  man  was  unfavorable 
when  the  wound  was  received. 

Second,  in  the  worst  cases  time  has  elapsed  before 
operation  is  practicable  and  peritonitis  is  already 
present. 

Third,  the  impossibility  of  knowing  just  what 
damage  is  done  necessitates  greater  risk  in  the  under- 
taking. 


CHAPTER  XIII 

TRENCH  DISEASES  AND  AVIATOR'S 
HEADACHE 

Trench  Frost  Bite. — This  name  is  applied  to  a  con- 
dition of  the  lower  extremities  resembling  gangrene. 
Although  it  has  been  termed  "  frost-bite, "  the 
parts  are  not  necessarily  frozen,  but  have  been 
subjected  to  a  prolonged  exposure  to  cold  and  wet. 
It  has  prevailed  in  the  trenches  because  early  in 
trench  warfare  the  lack  of  drainage  caused  the  feet 
and  legs  of  the  men  to  be  immersed  in  water  for 
days  and  weeks  at  a  time,  and  prolonged  exposure 
rather  than  the  degree  of  cold,  appears  to  be  respon- 
sible for  the  disease.  The  symptoms  are  those  of 
inflammation  caused  by  cold;  these  may  be  ery- 
thema only,  or  blisters  and  peeling  of  the  cuticle; 
sometimes  even  the  superficial  death  of  the  skin 
follows,  or  gangrene  of  some  portion.  Edema  occurs 
early  and  induration  of  the  tissues  will  damage  the 
muscle  fibers.  Results  of  experimental  research 
indicate  that  damage  to  the  blood-vessels  is  the  cause 
of  these  symptoms.  In  some  cases  the  vessels  rup- 
ture, causing  minute  hemorrhages  into  the  connec- 
tive tissues.  Usually  discoloration  of  the  skin  arises 

175 


1 76  WAR  NTOSING 

from  the  great  number  of  these  hemorrhages,  but 
although  they  produce  a  resemblance  to  the  color 
of  gangrene,  they  do  not  constitute  evidence  of  its 
presence. 

Trench  frost-bite  is  favored  by  the  fact  that  when 
in  the  trenches  the  soldier's  boots  are  almost  never 
removed  and  he  has  very  little  walking  exercise, 
as  the  men  have  at  times  been  obliged  to  remain  long 
in  one  station  with  the  feet  immersed  in  water. 
Special  care  in  the  treatment  of  these  cases  must  be 
exercised  to  prevent  rapid  return  of  circulation  in  the 
limbs;  the  application  of  heat  in  early  cases  is  there- 
fore contraindicated.  It  would  cause  congestion 
and  swelling  of  the  vessels  which  in  their  weakened 
state  they  would  not  be  able  to  withstand.  The 
precautions,  in  other  words,  are  similar  to  those 
exercised  in  the  care  of  frost-bite  under  any  cir- 
cumstances. 

The  resemblance  between  the  results  of  exposure 
to  freezing  temperature  and  those  of  long  exposure 
without  freezing,  have  led  to  the  use  of  the  same 
term  in  both  cases. 

A  somewhat  different  condition  has  been  called 
"trench  foot."  This  also  occurs  oftenest  in  cold 
rainy  weather.  Investigators  report  a  fungus  (not 
named)  which  invades  the  feet  of  those  standing 
long  in  the  water  of  the  trenches,  causing  peripheral 
neuritis  with  numbness,  prickling,  burning,  etc. 


TRENCH  DISEASES  AND  AVIATOR'S  HEADACHE      177 

Local  treatment  has  usually  cured  the  affection; 
occasionally  some  portion  of  the  toes  has  been  lost. 
Boric  acid  and  camphor  solution  are  used,  applied 
on  cotton  compresses.  Sometimes  copper  sulphate 
is  applied  in  addition.  It  is  claimed  that  amputa- 
tion has  not  followed  this  treatment  (further  than 
the  loss  of  part  of  the  toes),  although  septicaemia 
has  been  known  and,  rarely,  tetanus.  Neither  pa- 
tient nor  nurse  should  be  discouraged  by  the  grad- 
ual and  tedious  rate  of  improvement. 

Aviator's  headache  is  of  interest  although  not 
surgical.  It  is  probable  that  pathologic  conditions 
at  present  not  recognized  nor  explainable,  will  de- 
velop with  the  increased  number  of  army  aviators. 
The  problem  of  physiologic  adjustment  to  high 
altitudes  is  a  rather  serious  one;  as  the  man  ascends 
he  must  breathe  air  which  is  increasingly  rarefied, 
consequently,  he  is  getting  less  and  less  oxygen. 
This  leads  to  his  "aviator's  headache,"  rapid  heart 
action,  labored  respiration  and  general  discomfort. 
It  is  believed  by  some  physiologists,  that  by  a 
mysterious  and  fortunate  provision  of  Nature  oxy- 
gen is  extracted  from  living  tissues  and  delivered  to 
the  blood  in  the  lungs,  after  the  needs  of  the  system 
are  so  great  as  to  compel  it.  It  is  thought  that  this 
physiologic  process  will  be  developed  in  response  to 
the  demand,  and  for  those  who  are  training  for 
aviator's  work  a  gradual  process  of  adaptation  to 
rarefied  atmosphere  should  be  insisted  upon. 


178  WAR  NURSING  " 

The  treatment  of  "aviator's  headache"  is  in  the 
hands  of  the  patient.  More  oxygen  would  seem  to 
be  suggested. 

More  serious  conditions  and  symptoms  would  be 
due  to  suddenness  of  change  in  barometric  pressure. 
The  aviator  will  encounter  these  only  if  he  rises 
rapidly  to  a  height  of  20,000  feet,  which  is  hardly 
possible,  therefore  the  headache  and  loss  of  breath 
comprise  the  ills  he  has  to  meet,  with  the  addition 
of  extreme  changes  of  temperature.  All  these  may 
yet  bring  him  to  the  hospital. 

A  number  of  conditions  of  ill  health  among  the 
men  in  the  trenches  are  of  frequent  occurrence  and 
sufficiently  serious  to  require  hospital  care.  These 
are  not  surgical  cases,  therefore  will  not  be  described 
at  this  time.  Such  are  trench  fever,  and  various  forms 
of  malaria,  the  so-called  trench  nephritis,  with  the  oc- 
casional appearance  of  typhoid  and  para-typhoid 
fevers,  although  these  latter  have  been  largely  pre- 
vented by  the  immunizing  inoculations  which  are 
made  obligatory  in  some  armies,  notably  in  that  of 
the  United  States.  Sanitary  precautions  and  mod- 
ern methods  of  caring  for  troops  have  reduced  the 
number  of  cases  of  dysentery  which  in  the  past  has 
prevailed  extensively  among  them. 

The  entirely  unprecedented  methods  and  conditions 
of  the  present  war  have  been  accompanied  by 
equally  unforeseen  affections  more  or  less  serious  in 


TRENCH  DISEASES  AND  AVIATOR'S  HEADACHE      179 

their  consequences  to  the  health  and  the  life  of 
the  soldier.  For  instance — a  form  of  nephritis  has 
existed  among  the  men  in  the  trenches  which 
has  been  attributed  by  some  investigators  to  a 
special  infection.  A  certain  organism  (a  diplococcus) 
has  been  found  in  a  series  of  cases  under  observation. 
The  conditions  of  trench  life  are  of  themselves  suffi- 
cient to  cause  congestion  of  internal  organs  which 
would  make  them  peculiarly  sensitive  with  or  with- 
out the  invasion  of  specially  infectious  bacteria. 
Nephritis  of  such  origin  is  not  commonly  serious 
enough  to  threaten  life. 


INDEX 


Abdomen,  regions  of,  166 

operations  of,  more  serious  in 
war,  174 

surface  markings  of,  163-165 

viscera  of,  167,  168 

wounds    of,     dangers    com- 
pared, 1 68 
Aerobes,  14 

facultative,  14 
Agar  dressing,  53 
Agglutinins,  19 
Air  concussion,  134,  135 

hunger,  31 

cause  of,  32 
Ambrine,  91 
Anaerobes,  14,  25 

facultative,  14 
Antibodies,  19 
Antigen,  21 
Antisepsis,  38 
Antiseptics,  39,  40 
Asphyxiating  gas,  9 
Aviator's  headache,  177 

B 

Bacilli,  14-16 
Bacteria,  13,  14 
Bacterial  invasion,  17 
toxins,  15 


Bacteriology,  n,  13 

B.  I.  P.,  51 

Burns,  90 
ambrine  treatment  of,  91 

atomizer  for,  92 
effects  on  nerve  system,  27 
irrigation  treatment  of,  92 


Calcium  hypochlorite,  51 
Carrel  technique,  42 

tubes,  43 

Chest.     See  Thorax,  150 
Chloramins,  49 
Chlorazene,  50 

Combination  cigarette  drain,  57 
Complement,  17 
Condition  of  the  wounded,  65 
Cranial  surgery,  129-131 

D 

Dakin's  solution,  41,  42 

effects  on  tissues,  46 

merits  of,  47 

Diaphragm,  importance  of,  150 
Dichloramin-T,  50 


Excision  of  wounds,  71,  72 
Extension  apparatus,  74 
uses  of,  74,  75 


181 


182 


INDEX 


Plavine,  54 
Fractures,  75 

compound,  108 

dangers  of,  108 

of  lower  extremity,  109-115 

of  upper  extremity,  115-117 


Gangrene,  101 

a  premonitory  symptom  of, 
105 

dry,  i.o  i 

gas,  102-104 

moist,  101 

white,  104 
Gas,  asphyxiating,  9 
Glucose  solution,  37 


H 


Hemorrhage,  25,  30-32,  97,  98 

external,  32 

internal,  31,  32 

intracranial,  128 

secondary,  100 

treatment  of,  31-33*  97, 98, 99 
Hospitals,  64 
Hypochlorous  acid,  41 


Importance  of  directing  assis- 
tants, 134 
of  preparation,  2 


Immune  bodies,  19 
Immunity,  18 
acquired,  19 
artificial,  20 
natural,  19 
Injuries  of  the  abdomen,  163 

compared,  168-170 

effects  of,  171,  172 

nursing,  172-174 
of  blood  vessels,  97 

repair  of,  99 
of  bones,  repair  of,  106 

treatment  of,  106,  107 
character  of,  69 
of  the  chest  or  thorax,  154, 

155 

thoracic  viscera,  155,  157 
complications,  159 
symptoms,       nursing, 

157-159 
of  the  head,  126 

general  nursing,  127 

special  nursing,  133 

surgery  of,  129-131 

symptoms,  131-133 
of  joints,  117,  118 

ankle,  122 

elbow,  122 

hip,  119 

knee,  123,  124 

shoulder,  120 

wrist,  122 
of  the  neck,  138 
of  the  nerves,  145-148 
of  the  spine,  139,  140 

effects  of,  141-145 


INDEX 


Inspection  of  the  wounded  man, 

65-69 
Irrigation  barrier,  59 


Local  shock,  71 
Lymph,  40 

lavage,  41,  46,  52,  6 1 
importance  of,  41 

M 

Menciere's  balsam,  52 
Missiles,  8,  9 

O 

Opsonins,  19 

P 

Peritoneum,  168,  171 
Peritonitis,  171 
Phagocytes,  17,  19 
Picric  acid,  52 
Plaster  of  Paris,  84-88 
Pleura  (illustration),  152 


Repair  of  vessel  walls,  99 
Rose  irrigator,  56 


Scrobiculus  cordis,  165,  166 
Sepsis,  28 
Serum,  21,  22 
sickness,  23 
Shell  deafness,  136 

shock,  134 
Shock,  26,  27,  28,  67,  68 

treatment  of,  29,  30 
Soap  dressings,  51 
Splints,  75,  76 
aeroplane,  84 
Balkan  (frame),  82 
De  Puy,  double  inclined,  78 

wire  netting,  81 
Hodgen,  77 

Jones,  Robert,  abduction  (af- 
ter Thomas),  81 
humerus    extension    (after 

Thomas),  116 
leg  splint  (after  Thomas), 

"5 

Mclntyre,  77 
Thomas,  78,  79 
triangular,    83    (illustration, 

116) 

Sugar  dressings,  52 
Surgical  dressings,  38 


Saline  solutions,  intravenous  in- 
jection, 68 

introduction  of,  35,  36 
Salt  solutions,  effects  on  bac- 
teria, 59 

treatment,  54,  55,  60 
merits,  55 


Tetanus,  93 

antitoxin,  93,  94 

symptoms  of,  95 
Thorax,  organs  of,  152-154 

structure  of,  150 


I 84  INDEX 

Transportation  of  wounded,  63,  V 

Trtnch  diseases,  175  Vaccination,  *o,  „ 

foot,  ,76  symptoms,  23 

,      '    '  Vaccine,  22 
frostbite,  175 

nephritis,  179  W 

jj  Wounds,  8,  ii 

infected,  12 
Useful  hints  or  reminders,  4,  5,  6          spreading,  n,  157 


Hughes' 

Practice   of    Medicine 

llth  Edition 

By  Daniel  E.  Hughes,  M.D.,  M.A.,  Revised  and  in  parts  rewritten  by 
R.  J.  E.  Scott,  B.CJ,.,  Fellow  of  the  New  York  Academy  of  Medicine. 

TT  gives  the  synonyms,  definition,  causes,  symptoms,  pathology, 
diagnosis,  prognosis,  treatment,  etc.  of  each  disease  and  includes 
a  section  on  mental  diseases  and  diseases  of  the  skin. 

Hughes'  Practice  is  authorized  for  use  in  the  Syllabus  for  the 
Nurses'  Training  Schools  of  the  State  of  New  York.  It  is  particu- 
larly well  adapted  to  the  use  of  nurses  as  it  gives  just  such  informa- 
tion regarding  the  various  stages  of  a  disease  as  the  nurse  would  need 
to  know.  The  introductory  matter  includes  an  explanation  of  the 
various  medical  terms  such  as  pathology,  pathogenesis,  etiology,  mor- 
bid anatomy,  symptomatology,  pathognomonic,  physical  signs, 
complications,  diagnosis,  prognosis,  treatment,  etc.  There  is  also  a 
paragraph  on  terminology  which  is  very  helpful.  Under  each  disease 
valuable  suggestions  are  offered  which  the  nurse  could  use.  For 
example,  under  MEASLES,  after  fully  describing  the  symptoms, 
complications,  diagnosis,  etc.,  the  author  says:  "isolation,  rest  in  bed, 
protection  from  drafts  and  from  bright  light  are  necessary  from  the 
onset  of  the  disease.  It  is  often  desirable  to  give  a  diaphoretic  mix- 
ture such  as  the  following  (here  is  given  prescription).  The  bowels 
should  be  kept  regular  by  means  of  some  mild  laxative.  The  diet 
should  be  semi-solid.  Mild  cases  require  no  medicines.  Cold 
sponging,  or  the  following,  will  reduce  temperature  when  it  becomes 
alarmingly  high  (here  is  given  prescription  and  directions).  Daily 
inunctions  of  cold  cream,  cocoa-butter,  eucalyptol  in  petrolatum, 
and  similar  oily  substances  will  serve  to  relieve  the  itching,  etc. 
The  book  is  practical,  and  handy  in  size  for  travelers. 

63  Illustrations,   12mo,  804  Pages.    Cloth,  $3.00.     Full 
Limp  Leather,  Gilt  Edges,  Round  Corners.    $3.25  Postpaid. 


P.     BLAKISTON'S     SON     &     COMPANY 
PUBLISHERS       -       -     PHILADELPHIA 


American  Red  Cross  Text-Book  on 

Elementary  Hygiene 

And    Home    Care   of    the    Sick 

By  Jane  A.  Delano,  R.N.,  Chairman  National  Committee  Red  Cross 
Nursing  Service,  Washington,  D.  C.  and  the  late  Isabel  Mclsaac,  R.N., 
formerly  Superintendent  of  the  Nurses  Corps,  U.  S.  A.,  with  a  Preface 
by  Miss  Mabel  T.  Boardman,  Chairman  National  Relief  Board, 
American  Red  Cross. 

IN  this  book  preventive  measures  are  dealt  with  at  some 
length  so  that  the  text  is  very  practical  and  of  real  in- 
terest and  value  to  the  nurse.     The  figure  shows  a  fly  with 

germs  (greatly  mag- 
nified) on  its  legs  and 
is  an  example  of  the 
care  taken  to  make 
things  clear  through- 
out the  text. 

The  folio  wing  sub- 
jects are  discussed: 
Bacteria,  Causes 
and  transmission  of 

disease,  Food,  Water,  Ice,  Air,  Ventilation,  Heating,  Lighting, 
Soil,  Sewage,  Garbage,  The  House,  Care  of  the  House, 
Laundry,  Personal  Hygiene,  Public  agencies  of  Health  and 
Welfare,  Hygiene  of  Infancy  and  Childhood,  Beds,  Mat- 
tresses, Pillows,  Bedding,  Bed  Making,  Care  of  sick  at 
Home,  General  care  of  patient,  Use  of  appliances,  Local 
applications,  Enemata,  Symptoms  of  Disease,  Medicine 
Closet,  Appendix:  List  of  Books,  Pamphlets,  Circulars, 
Recipes,  etc.,  Index. 

REVIEW 

"This  is  an  excellent  little  b9ok.  Hygiene,  whether  elementary 
or  not,  is  a  question  of  primary  importance — a  real  living  presence, 
a  practical  art  destined  to  take  the  place  of  over-much  pharmacolog- 
ical and  serum  science  of  the  time." — New  York  Medical  Journal. 

17  Illustrations,  12mo,  271  Pages. 
Cloth,  $1.00  Postpaid.    Paper  Covers,  $.50  Postpaid. 

P.  BLAKISTON'S  SON  &  COMPANY 
PUBLISHERS  -  -  PHILADELPHIA 


American  Red  Cross 

Textbooks  on  First  Aid 

THIS  series  of  textbooks  on  first  aid  was  prepared  expressly  f9r 
and  endorsed  by  the  American  Red  Cross.  It  is  published  in 

several  editions  to  meet  the  needs  of  particular  classes.     The  body 

of  all  of  these  editions  is  identical,  as  the  most  essential  facts  in 

respect  of  first  aid  are  the  same,  but  in  order  to  adapt  each  to  the 

needs  of  those  for  whom  it  is  designed,  appropriate  chapters  have 

been  added  to  the  book  for  each  edition. 

FIRST  AID  AND  RELIEF  COLUMNS  treats  not  only  of  first  aid  as 
given  by  the  individual,  but  also  of  relief  columns,  bodies  designed 
to  administer  first  aid  as  organizations.  Army  conditions  empha- 
size the  necessity  for  the  creation  of  organizations  in  order  that 
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aid.  By  Lieut.  Colonel  Charles  Lynch,  Medical  Corps,  U.  S.  A. 
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THE  GENERAL  EDITION  is  for  use  in  mixed  classes  or  wherever  it 
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American  Red  Cross  Text- Book  on 

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SYNOPSIS  OF  THE  CONTENTS 

HYGIENE  OF  FOOD  DIGESTION 

NUTRIENTS  FUEL  VALUE  AND  DIETARY 

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